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STREPTOCOCCI
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STREPTOCOCCI: CLASSIFICATION

• Gram-positive cocci (like staphylococcus)

• Catalase negative (unlike staphylococcus)

• Divided into three groups based on their ability to break

down (hemolyze) red blood cells

• Classified based on the antigenic characteristics of the C

carbohydrate found on the cell wall

GROUPING BASED ON HEMOLYSIS

• Beta-hemolytic streptococci completely lyse the RBCs

• leaving a clear zone of hemolysis around the colony

• Alpha-hemolytic streptococci only partially lyse the RBCs

• leaving a greenish discoloration of the culture medium surrounding the colony.
• discolored area contains unlysed RBCs and a green-colored metabolite of
hemoglobin

• Gamma-hemolytic streptococci are unable to hemolyze the RBCs

• Non-hemolytic streptococci
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GROUPING BASED ON LANCEFIELD

ANTIGEN

• Based on the antigenic characteristics of the C

carbohydrate found on the cell wall

• Lancefield antigen (after Rebecca Lancefield, 1930s)

• 20 Lancefield groups, each designated by a letter

• Important Lancefield groups are groups A, B and D

• Historically, was a major way of differentiating the many

Streptococci

MEDICALLY IMPORTANT
STREPTOCOCCI

• Lancefield Group A Streptococci

• Lancefield Group B Streptococci
• Lancefield Group D Streptococci
• Viridans Group Streptococci
• Streptococcus pneumoniae
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GROUP A BETA-HEMOLYTIC
STREPTOCOCCI (GABS)

• Belong to the Lancefield A group, beta-hemolytic

• also called Streptococcus pyogenes
• Pyon – Greek meaning “pus”

• Causes
• Throat infection (strep throat)
• Scarlet fever
• Rheumatic fever
• Post-streptococcal glomerulonephritis

VIRULENCE FACTORS FOR GROUP A BETA-

HEMOLYTIC STREPTOCOCCI (GABS)

• M protein
• Major virulence factor for group A streptococcus
• Inhibits activation of complement system and protects the
bacteria from phagocytosis

• Weakest part of the bacterial defense

• Plasma (B) cells generate antibodies against the M protein
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VIRULENCE FACTORS FOR GROUP A BETA-

HEMOLYTIC STREPTOCOCCI (GABS)

• Streptolysin O
• “O” stands for “oxygen labile” - inactivated by oxygen
• Destroys RBCs and WBCs
• Reason for the beta-hemolytic ability
• Antigenic  infection produces anti-streptolysin O (ASO) antibodies

• Streptolysin S
• “S” stands for “oxygen stable”
• Also causes hemolysis
• Not antigenic
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VIRULENCE
GROUP
FACTORS
A BETA-HEMOLYTIC
FOR GROUP A BETA-
HEMOLYTIC
STREPTOCOCCI
STREPTOCOCCI
(GABS)
(GABS)

• Pyrogenic exotoxin (erythrogenic toxin):

• Found in only a few strains of beta-hemolytic group A streptococci
• Cause scarlet fever

• Other enzymes such as

• Streptokinase – degrades blood clots
• Peptidases – degrades proteins
• Hyaluronidase – degrades hyaluronic acid

GROUP A BETA-HEMOLYTIC
STREPTOCOCCI (GABS) - DISEASES

Disease by local invasion and/or Disease by delayed antibody

exotoxin release mediated response

• Streptococcal pharyngitis • Rheumatic fever

• Streptococcal skin infections • Post-streptococcal

glomerulonephritis
• Scarlet fever

• Streptococcal toxic shock

syndrome
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DISEASE BY LOC AL
INVASION/EXOTOXIN RELEASE

• Streptococcal pharyngitis
• Red swollen tonsils and pharynx
• Purulent exudate on the tonsils
• High fever
• Swollen lymph nodes
• Usually lasts 5 days
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DISEASE BY LOC AL
INVASION/EXOTOXIN RELEASE

• Skin infections:
• Follicullitis – infection of the hair follicles

• Cellulitis - a deep infection of the skin cells

• Red, swollen skin which feels hot when touched

• Impetigo – blisters
• Common in children, frequently around the mouth
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DISEASE BY LOC AL
INVASION/EXOTOXIN RELEASE

• Necrotizing Fasciitis ("Flesh-eating infection")

• M proteins block phagocytosis, allowing the bacteria to move

rapidly through tissue

• Streptococci enter through a break in the skin caused by

trauma  follow a path along the fascia (connective tissue)
which lies between the subcutaneous tissue and muscle

• Within a day the patient develops swelling, heat, and redness that moves
rapidly from the initial skin infection site

• A day later the skin color changes from red to purple to blue, and large
blisters (bullae) form

• Later the skin dies and muscle may also become infected (myositis)

• Even with antibiotics and surgery the mortality rate is high

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DISEASE BY LOC AL
INVASION/EXOTOXIN RELEASE

• Scarlet fever:
• Pyrogenic toxin or erythrogenic toxin produces fever and a scarlet-
red rash
• “pyr” – Greek meaning “fire or heat”
• “erythros – Greek meaning “red” or “reddish”

• Rash begins on the trunk and neck, and then spreads to the
extremities, initially sparing the face

• Skin may peel off in fine scales during healing

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DISEASE BY LOC AL
INVASION/EXOTOXIN RELEASE

• Streptococcal toxic shock syndrome

• Mediated by the release of pyrogenic toxin

• Similar to toxic shock syndrome like that caused by

Staphylococcus aureus

• Fever, chills, myalgia (painful muscles), nausea and

vomiting

• Hypotension, tachycardia, tachypnea, organ failure

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DELAYED ANTIBODY-MEDIATED DISEASE

• Acute Rheumatic Fever

• Post-streptococcal Glomerulonephritis

DELAYED ANTIBODY-MEDIATED DISEASE

• Acute Rheumatic Fever

• Follows untreated beta-hemolytic group A streptococcal pharyngitis

and skin infection

• Autoimmune response to S. pyogenes infection involving multiple

organ systems

• Now uncommon due to treatment of streptococcal pharyngitis with

antibiotics

• Usually strikes children 5-15 years of age

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RHEUMATIC FEVER: 6 MAJOR MANIFESTATIONS

• Fever

• Myocarditis (heart inflammation) – chest pain, abnormal heart beat,

heart failure

• Arthritis (joint inflammation)

• Chorea (uncontrolled dance-like movements of the extremities) -

usually begins 2-3 weeks after the pharyngitis

• Subcutaneous nodules (rubbery nodules just under the skin)

• Rash (erythema marginatum)

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DELAYED ANTIBODY-MEDIATED DISEASE

• Acute post-streptococcal glomerulonephritis:

• Antibody-mediated inflammatory disease of the glomeruli of the kidney

• Occurs about 1 week after infection of the pharynx or skin by

nephritogenic strains of beta-hemolytic group A streptococci
• Nephritogenic streptococci – have the ability to cause glomerulonephritis

• Antigens from nephritogenic streptococci induce an antibody response

• Antigen-antibody complexes travel in the blood and are deposited in the

glomerular basement membrane  leads to local glomerular destruction in
the kidney

ACUTE POST-STREPTOCOCCAL
GLOMERULONEPHRITIS

• Symptoms
• Edema – fluid retention
• Hematuria and proteinuria – blood and protein in the urine
• Hypertension – elevated blood pressure

• Essentially a disease of childhood that accounts for

approximately 90% of renal disorders in children
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GROUP B STREPTOCOCCI

• Beta-hemolytic
• Common bacterium often carried in the intestines or
lower genital tract
• Usually harmless in healthy adults

• Cause serious illness in newborns, known as Group B

strep (GBS) disease
• Meningitis, pneumonia, bacteremia, bone/joint infection, skin/soft
tissue infection in neonates (<3 months old)
• Bacteria is acquired from the mother’s vaginal tract during delivery

VIRIDANS GROUP STREPTOCOCCI

• Big, heterogeneous group of streptococci

• No Lancefield antigen classification
• Most are Alpha-hemolytic
• producing greenish discoloration on blood agar
• “Viridis” - Latin word for green

• Include Streptococcus salivarius, S. sanguis, S. mitis, S.

intermedius, S. mutans, and others
• Normal human gastro-intestinal (G.I.) tract flora that are
frequently found in the nasopharynx and gingival crevices
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VIRIDANS GROUP STREPTOCOCCI

• 3 main types of infection:

• Dental infections/Tooth decay
• bind to teeth and ferment sugar  produces acid and dental caries
(cavity)

• Endocarditis
• Dental procedures send the bacteria into the bloodstream  implant
on the heart valves (more commonly on a previously damaged valve)
• Dextran allows bacteria to attach to the heart valves and slow grow and
multiply
• Subacute bacterial endocarditis – low grade fever, anemia, fatigue, heart
murmurs
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VIRIDANS GROUP STREPTOCOCCI

• 3 main types of infection:

• Abscesses
• Caused by the microaerophilic Streptococcus intermedius group
(comprised of Streptococcus intermedius, S. constellatus, and S. anginosus)

Treatment of internal abscess by CT-guided percutaneous drainage

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GROUP D STREPTOCOCCI

• Streptococcus bovis/Streptococcus equinus complex

• Alpha-hemolytic or Gamma-hemolytic/non-hemolytic
• Comprised of many organisms – S. bovis is the most popular

• S. bovis
• Considered normal bowel flora
• Causes urinary tract infections, biliary tract infections, bacteremia, and
subacute bacterial endocarditis
• Associated with colorectal cancer

• Enterococci used to be classified under group D streptococci but now have

their own genus, Enterococcus

STREPTOCOCCUS PNEUMONIAE

• Also known as Pneumococcus

• No Lancefield antigen
• Alpha-hemolytic
• Major cause of bacterial pneumonia
and meningitis in adults
• Major cause of otitis media in children
• Under the microscope, they appear as
lancet-shaped gram-positive cocci
arranged in pairs (diplococci)
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STREPTOCOCCUS PNEUMONIAE

• Polysaccharide capsule – most important virulence factor

• Antigenic – antibodies can neutralize the capsule
• Approximately 100 serotypes of pneumococcal capsule are known

• 2 tests to identify the pneumococcus

• Quellung reaction:
• Antiserum (serum with antibodies) and methylene blue are applied to bacteria on the slide smear
• Bacterial capsule will appear to swell if it is pneumococcus

• Optochin sensitivity: used to differentiate S. pneumoniae from S. viridans (both alpha-hemolytic)

• Disc impregnated with optochin is placed on the agar dish
• S. pneumoniae growth will be inhibited; S. viridans will continue to grow
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STREPTOCOCCUS PNEUMONIAE

• Pneumococcal pneumonia
• Shaking chills (rigors), high fevers, chest pain with respirations, and
shortness of breath
• Air sacs of the lungs fill up with white blood cells (pus), bacteria, and
exudate
• Seen on the chest X-ray as a white area in the lung called
“consolidation”
• Patient will cough up yellow-green phlegm
• Gram staining of the phlegm will reveal gram-positive lancet-
shaped diplococci
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STREPTOCOCCUS PNEUMONIAE

• Otitis media in children

• Infection of the middle ear
• Usually follows upper respiratory tract infection
• Ear pain (most common complaint), ear discharge, hearing difficulties,
fever

• Bacterial meningitis in adults

• Inflammation (swelling) of the protective membranes covering the brain
and spinal cord
• Sudden high fever, stiff neck, severe headache that seems different from
normal, headache with nausea or vomiting, confusion or difficulty
concentrating, seizures, sleepiness or difficulty waking
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STREPTOCOCCUS PNEUMONIAE

• Prevention – pneumococcal vaccine

• Composed of partially purified pneumococcal capsular polysaccharides.
• Recommended for:
• All adults ≥65 years of age
• Adults aged 19 to 64 years with:
• Predisposing chronic medical conditions (eg, chronic lung disease, chronic liver disease, diabetes
mellitus)
• Increased risk of meningitis (cochlear implant, cerebrospinal fluid [CSF] leak)
• Immunocompromising conditions (human immunodeficiency virus (HIV) infection, hematologic
malignancies)
• Asplenia (anatomical or functional absence of the spleen)

READING ASSIGNMENT FOR TUESDAY: Enterococci and other

Catalase-Negative Gram-positive Cocci