Streptococcus

J. Walter Sowell, R.Ph., Ph.D.

General Characteristics of Genus



Diverse group of gram-positive cocci which grow in chains in broth or individually, in pairs, or as short chains on solid media Some Streptococcus have capsules
 

Streptococcus pyogenes Streptococcus pneumoniae

Most species are facultative anaerobes but a few range from anaerobic to capnophilic (requires carbon dioxide)
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General Characteristics of Genus

  

Energy is derived by carbohydrate fermentation with lactic acid production Unlike Staphylococci, this genus is catalase negative Preliminary laboratory identification is based on hemolytic reactions on 5% sheep blood agar plates

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Beta-Hemolytic Streptococci

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Serologic Classification for Streptococcus species

  

Rebecca Lancefield (1933) developed technique Based on immunoassay of group antigen in cell wall Within cell wall Group specific and Type-specific antigens  Group antigen = N-acetylglucosamine-Rhamnose  Group A Streptococci  Group antigen = Glucosamine polysaccharide-Rhamnose  Group B Streptococci  Group antigen = N-acetylgalactosamine Rhamnose  Group C Streptococci
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Importance of Lancefield Classification



Rapid identification of pathogen Group antigen within the cell wall  Immunoassay from a throat swab Quick way to identify Streptococcus pyogenes as the pathogen in pharyngitis  Often used in physicians offices or the hospital to identify pathogen
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Limitation of Lancefield Classification



Many species of Streptococci lack a group antigen



Require other biochemical tests for identification

Lancefield classification used for a few species



Group A, B, C, F, and G

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Streptococcus pyogenes (Group A)



General Characteristics/Classification


 

Possesses a specific carbohydrate antigen in the cell wall called the C antigen. This antigen is used to separate the various species of Streptococcus into multiple groups: A, B, C, D, F, and G Serological Classification Group A Hemolytic Pattern Beta hemolytic
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S. pyogenes


General Characteristics (cont)



M protein, a major surface antigen, is present on the fimbriae of this pathogen

Subdivides Group A into multiple immunologic types 100+  Clinical importance?? Differ serotypes are associated with causing disease. It is type specific. Serves as a basis for preventing reinfection  Antiphagocytic  Immunity is type specific (based on M protein) G9  Important in epidemiological studies


S. pyogenes
 

Habitat lives on human skin and mucous membranes Transmission > Respiratory tract droplets from a carrier > Fomites (pens, paper, drinking glasses)

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S. pyogenes Virulence Factors



Structural Components


Capsule


Some strains have a hyaluronic acid capsule



Nonimmunogenic and antiphagocytic

Hyaluronic acid is an important component of connective tissue



Capsule is recognized as natural by the immune system

Encapsulated strains more likely to cause severe systemic infections

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S. pyogenes Virulence Factors



Structural Components (cont)



M Protein
The M protein on fimbriae serves as a major surface antigen and serves as the basis for the subdivision within Streptococcus pyogenes  It is antiphagocytic and serves to degrade one of the components of complement


F Protein


May participate in tight binding of the pathogen to the epithelial cells of the throat and skin
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S. pyogenes Virulence Factors



Enzymes Secreted by the Pathogen



Streptolysin O (oxygen labile)



Antigenic Antibodies formed against this antigen helpful when testing for a recent infection by this pathogen


Antibodies against Streptolysin O (ASO) appear 3 to 4 weeks after initial infection and persist

Lyses blood cells (WBC, RBC, platelets)

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S. pyogenes Virulence Factors



Enzymes Secreted by the Pathogen (cont)



Streptolysin S (oxygen stable)

Nonantigenic  Lyses blood cells (WBC, RBC, platelets)


Streptokinase
Lyses blood clots  Dissemination factor


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S. pyogenes Virulence Factors



Enzymes Secreted by the Pathogen (cont)



DNases A D
Lyses DNA  Dissemination factor  Pus, which contains DNA, is more fluid with Streptococcus infections in comparison to Staphylococcus infections


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S. pyogenes Virulence Factors



Streptococcal Pyrogenic Exotoxins (previously called Erythrogenic Toxins)  Four types (Toxin A, B, C, and F)  Possibly responsible for clinical manifestations seen in severe reactions  Rash in Scarlet fever  Necrotizing fasciitis  Streptococcal toxic shock syndrome  Phage mediated  Toxins are classified as a superantigen  Bridge Macrophages to Helper T cells  Hyper response of the immune system shock, organ failure, and death

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Streptococcus pyogenes-CDC
  

In 2005, CDC reports that 4700 cases of invasive disease in the U.S. Perhaps, 10 million cases of noninvasive disease, mostly pharyngitis and pyoderma Pharyngitis caused by Streptococcus pyogenes is most often seen in children, ages 5 to 15 years, but certainly not limited to this age range.
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S. pyogenes Suppurative Diseases



Pharyngitis (Strep Throat)



Fever, sore throat, redness, and edema of the mucous membranes, purulent exudates, and enlargement of the cervical lymph nodes May extend to middle ear, mastoid, and meninges

 

Pyoderma (Impetigo) Vesicles Pustules (pus filled) Rupture Crust Puerperal Sepsis postpartum infection of uterus

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S. pyogenes Suppurative Diseases



Cellulitis of skin
 

Involves deeper subcutaneous tissue with rapid spread Often the result of damage to skin (burn or wound)

Post-surgical Wound Infection Onset of symptoms of infection occur rapidly (6-12 hours), while 48 hours or longer with Staphylococcus aureus
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S. pyogenes Suppurative Diseases



Scarlet Fever
  

Complications of pharyngitis Rash caused by pyrogenic exotoxins Within a couple of days after initial symptoms of pharyngitis, a red rash appears on upper chest and spreads to extremities

 

Erysipelas rash on skin as a complication of pharyngitis Pneumonia

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S. pyogenes Suppurative Diseases



Necrotizing fasciitis(Streptococcal gangrene)

  

An infection that occurs in the deep subcutaneous tissue Very rapid movement Flesh eating bacteria that causes death to fascia and destruction to muscle and fat

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S. pyogenes Suppurative Diseases



Streptococcal Toxic Shock Syndrome

  

Typically occurs in association with necrotizing fasciitis or bacteremia Rapidly progresses to shock and death due to organ failure (kidneys, lungs, liver, heart) See Clinical Case 22-1 of Textbook-Page 231 (Note how rapidly this patient declined!!)

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Erysipelas

Necrotizing fasciitis

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S. pyogenes Nonsuppurative Diseases



Acute Glomerulonephritis


 

Associated with untreated skin or respiratory tract infections caused by nephritogenic strains of S. pyogenes, Group A Onset of symptoms may be as short as one week after infection Evidence strongly support a Type III hypersensitivity reaction, where the antigen-antibody complex is trapped in the glomerular membranes Symptoms include hypertension, edema, BUN, serum creatinine, blood and protein in urine
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S. pyogenes Nonsuppurative Diseases



Acute Rheumatic Fever

    

Greatly reduced incidence in U.S. (only 112 cases in 1994) Far more prevalent in developing countries Associated with untreated upper respiratory tract infections, usually pharyngitis Onset of symptoms 1 4 weeks post S. pyogenes infection M protein of the pathogen shares some common structural features with certain cardiac tissue. M protein serves as an antigen which induces antibody formation. A Type II hypersensitivity reaction may occur with the antibody binding to cardiac tissue, causing inflammation and cardiac damage
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S. pyogenes Diagnosis


Rapid antigen detection from specimen

 

Release the C antigen by enzymatic or chemical means Detection of the C antigen with ELISA or latex agglutination

If rheumatic fever is suspected, high ASO titers (Antibody to Streptolysis O) would confirm a recent Streptococcus pyogenes infection If acute glomerulonephritis is suspected, high anti-DNase B titers would confirm a recent Streptococcus pyogenes skin infection

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Streptococcus agalactiae (Group B)



General Characteristics/Classification
  

Serological classification Group B Hemolytic pattern beta hemolytic, but narrow zone Growth pattern short chains long chains

 

Habitat GI and female genital tracts Transmission Can be transmitted to unborn, in utero, or to newborn during birth
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Streptococcus agalactiae (Contd)



Early-Onset Neonatal
   

Late-Onset Neonatal
   

Birth 1st week of life Bacteremia, pneumonia, or meningitis Mortality rate-5% or so Meningitis survivalSignificant neurological effects (blindness, deafness, mental retardation)

One week 3 months Bacteremia with meningitis Neurological effects high with meningitis See Case 22-2-p 235

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S. agalactiae - Diseases


Adults
 

After deliver, the pathogen can cause endometritis . Pathogen may cause UTI Older adults with compromised immunity
Bacteremia, bone and joint, skin and soft-tissue, pneumonia  Mortality rate fairly high


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S. agalactiae


Laboratory Diagnosis
 

Culture pathogen Detection of Serologic markers from pathogen

Antibody reaction with the group B antigen of the cell wall (Ex: latex agglutination)  Nine type-specific capsule polysaccharides  Surface protein antigens


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