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Streptococcal Toxic Shock—like Syndrome

Streptococcal Toxic Shock—like Syndrome Abstract Background: After decades marked by a decrease in the incidence and severity of scarlet fever and streptococcal soft-tissue infections, invasive infections with group A streptococci have reemerged as a global public health problem. Sporadic outbreaks of a rapidly progressive disorder characterized by fever, shock, desquamating rash, and multiorgan system failure often associated with severe suppurative soft-tissue infection have recently been recognized in young, otherwise-healthy adults. Referred to as streptococcal toxic shock—like syndrome, this acute, progressive, often fatal illness appears to be related to an overall change in the virulence of group A streptococci and the reappearance of highly mucoid exotoxin-producing strains. However, the relationship between virulence factors, epidemiological features, and precise pathogenesis of these infections remains unclear. Observations: The 80% incidence of soft-tissue involvement in streptococcal toxic shock—like syndrome and the high frequency of progression to necrotizing fasciitis, myositis, or even death are unprecedented. The type and extent of tissue injury, systemic toxicity, and multiorgan system failure associated with this syndrome appear to be mediated by streptococcal pyrogenic exotoxins via the induction of biologically potent endogenous cytokines. The observed increase in the incidence and severity of invasive group A streptococcal infections coincides with the resurgence of genetically related, highly virulent strains of Staphylococcus pyogenes that express an invasive phenotype and carry a specific gene for pyrogenic exotoxin A. Conclusions: The changing spectrum of invasive group A streptococcal infections has prompted a reexamination of the microorganism and its diverse clinical manifestations. A clonal basis for increased virulence expression is supported epidemiologically. As the incidence of streptococcal toxic shock—like syndrome appears to be increasing, it is imperative that clinicians become familiar with the presentation of this syndrome so they can diagnose and treat it in a timely and effective manner.(Arch Dermatol. 1995;131:73-77) References 1. Quinn R. Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever . Rev Infect Dis. 1989;11:928-953.Crossref 2. Veasy L, Wiedmeier S, Orsmond G, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States . N Engl J Med. 1987;316:421-427.Crossref 3. Bartter T, Dascal A, Carroll K, Curley F. 'Toxic strep syndrome': a manifestation of group A streptococcal infection . Arch Intern Med. 1988;148:1421-1424.Crossref 4. Butler J, Schwartz B, Kimball J, Davis J. Severe illness associated with group A—hemolytic streptococcal infections . Wis Med J. 1991;90:525-529. 5. Cone L, Woodard D, Schlievert P, Tomory G. Clinical and bacteriologic observations of a toxic shock—like syndrome due to Streptococcus pyogenes . N Engl J Med. 1987;317:146-149.Crossref 6. Makela P, Jahkola M. Group A streptococci must be taken seriously . Finn Med J. 1989;44:418-422. 7. Margolis D, Horlick S. Group A streptococcus—induced bullous toxic shock— like syndrome . J Am Acad Dermatol. 1991;24:786-787.Crossref 8. Reid R, Briggs R, Seal D, Pearsom A. Virulent Streptococcus pyogenes: outbreak and spread within a geriatric unit . J Infect. 1983;6:219-225.Crossref 9. Ruben F, Norden C, Heisler B, Korica Y. An outbreak of Streptococcus pyogenes infections in a nursing home . Ann Intern Med. 1984;101:494-496. 10. Stevens D, Tanner M, Winship J, et al. Severe group A streptococcal infection associated with a toxic shock—like syndrome and scarlet fever toxin A . N Engl J Med. 1989;321:1-7.Crossref 11. Thomas J, Carr S, Fujioka K, Waterman S. Community-acquired group A streptococcal deaths in Los Angeles county . J Infect Dis. 1989;160:1086-1087.Crossref 12. Wood T, Potter M, Jonasson O. Streptococcal toxic shock—like syndrome: the importance of surgical intervention . Ann Surg. 1993;217:109-114.Crossref 13. Peter G, Smith A. Group A streptococcal infections of the skin and pharynx . N Engl J Med. 1977;297:311-316.Crossref 14. Wannamaker L. Differences between streptococcal infections of the throat and of the skin . N Engl J Med. 1970;282:78-85.Crossref 15. Wannamaker L. Streptococcal toxins . Rev Infect Dis. 1983;5( (suppl 4) ):S723-S732.Crossref 16. Musser J, Hauser A, Kim M. Streptococcus pyogenes causing toxic shock— like syndrome and other invasive diseases: clonal diversity and pyrogenic exotoxin expression . Proc Natl Acad Sci U S A. 1991;88:2668-2672.Crossref 17. Cleary P, Kaplan E, Handley J, et al. Clonal basis for resurgence of serious Streptococcus pyogenes disease in the 1980's . Lancet . 1992;339:518-521.Crossref 18. Schwartz B, Facklam R, Breiman R. Changing epidemiology of group A streptococcal infection in the USA . Lancet . 1990;336:1167-1171.Crossref 19. Ferrieri P. Microbiologic features of current virulent strains of group A streptococci . Pediatr Infect Dis J. 1991;10( (suppl) ):S20-S24.Crossref 20. Hensler T, Koller M, Geoffroy C, Alouf J, Konig W. Staphylococcus aureus toxic shock syndrome toxin 1 and Streptococcus pyogenes erythrogenic toxin A modulate inflammatory mediator release from human neutrophils . Infect Immun. 1993; 61:1055-1061. 21. Hackett S, Schlievert P, Stevens D. Cytokine production by human mononuclear cells in response to streptococcal exotoxins . Clin Res. 1991;39:189A. Abstract. 22. Hackett S, Stevens D. Streptococcal toxic shock syndrome: synthesis of tumor necrosis factor and interleukin-1 by monocytes stimulated with pyrogenic exotoxin A and streptolysin O . J Infect Dis. 1992;165:879-885.Crossref 23. Schlievert P. Role of superantigens in human disease . J Infect Dis. 1993;167:997-1002.Crossref 24. Mollick J, Rich R. Characterization of a superantigen from a pathogenic strain of Streptococcus pyogenes . Clin Res. 1991;39:213A. Abstract. 25. Stevens D. Invasive group A streptococcus infections . Clin Infect Dis. 1992; 14:2-13.Crossref 26. Bisno A. Streptococcus pyogenes . In: Mandell G, Douglas R, Bennett J, eds. Principles and Practice of Infectious Diseases . 3rd ed. New York, NY: Churchill Livingstone Inc; 1990:1519-1528. 27. Bradley J, Schlievert P, Sheehan P. Streptococcal toxic shock—like syndrome as a complication of primary varicella . Pediatr Infect Dis J. 1991;10:77-78.Crossref 28. Semel J. Streptococcal toxic shock syndrome following influenza A infection . Infect Dis Clin Pract. 1993;2:118-119. 29. Vuzevski V, VanJoost T, Wagenvoort J, Dey JM. Cutaneous pathology in toxic shock syndrome . Int J Dermatol. 1989;28:94-97.Crossref 30. Scott R, Naidoo J, Lightfoot N, George R. A community outbreak of group A beta-haemolytic streptococci with transferable resistance to erythromycin . Epidemiol Infect. 1989;102:85-91.Crossref 31. Breiman R, Davis J, Facklam R, et al. Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition . JAMA . 1993;269:390-391.Crossref 32. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis: the use of frozen-section biopsy . N Engl J Med. 1984;310:1689-1693.Crossref 33. Bernaldo de Quiros J, Moreno S, Munoz P, Rodriguez-Creixems M, Catalan P, Bouza E. Antigen detection in the rapid diagnosis of severe extrapharyngeal infections caused by group A streptococcus . Infect Dis Clin Pract. 1992;1:372-376. 34. Chesney PJ. Clinical aspects and spectrum of illness of toxic shock syndrome: overview . Rev Infect Dis. 1989;11( (suppl 1) ):S1-S7.Crossref 35. Gastanaduy A, Kaplan E, Huwe B, McKay C, Wannamaker L. Failure of penicillin to eradicate group A streptococci during an outbreak of pharyngitis . Lancet . 1980;2:498-502.Crossref 36. Kim K, Kaplan E. Association of penicillin tolerance with failure to eradicate group A streptococci from patients with pharyngitis . J Pediatr. 1985;107:681-684.Crossref 37. Adams E, Gudmundsson S, Yocum D, Haselby R, Craig W, Sundstrom W. Streptococcal myositis . Arch Intern Med. 1985;145:1020-1023.Crossref 38. Eagle H. Experimental approach to the problem of treatment failure with penicillin, I: group A streptococcal infection in mice . Am J Med. 1952;13:389-399.Crossref 39. Sanders E, Foster M, Scott D. Group A beta-hemolytic streptococci resistant to erythromycin and lincomycin . N Engl J Med. 1968;278:538-540.Crossref 40. Perez-Trallero E, Garcia-Arenzana J, Urbieta-Ergana M. Erythromycin resistance in streptococci . Lancet . 1989;2:444-445.Crossref 41. Witler R, Yamada S, Bass J, Hamill R, Wiebe R, Ascher D. Penicillin tolerance and erythromycin resistance of group A β-hemolytic streptococci in Hawaii and the Philippines . AJDC . 1990;144:587-589. 42. Holmstrom L, Nyman B, Rosengren M, Wallander S, Ripa T. Outbreaks of infection with erythromycin-resistant group A streptococci in child day care centres . Scand J Infect Dis. 1990;22:179-185.Crossref 43. Seppala H, Nissinen A, Jarvinen H, et al. Resistance to erythromycin in group A streptococci . N Engl J Med. 1992;326:292-297.Crossref 44. Weisblum B. Inducible resistance to macrolides, lincosamides and streptogramin type B antibiotics: the resistance phenotype, its biological diversity and structural elements that regulate expression: a review . J Antimicrob Chemother. 1985;16( (suppl A) ):63-90. 45. Gray G, Escamilla J, Hyams K, Struewing J, Kaplan E, Tupponce A. Hyperendemic Streptococcus pyogenes infection despite prophylaxis with penicillin G benzathine . N Engl J Med. 1991;325:92-97.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Streptococcal Toxic Shock—like Syndrome

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.1995.01690130075014
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Abstract

Abstract Background: After decades marked by a decrease in the incidence and severity of scarlet fever and streptococcal soft-tissue infections, invasive infections with group A streptococci have reemerged as a global public health problem. Sporadic outbreaks of a rapidly progressive disorder characterized by fever, shock, desquamating rash, and multiorgan system failure often associated with severe suppurative soft-tissue infection have recently been recognized in young, otherwise-healthy adults. Referred to as streptococcal toxic shock—like syndrome, this acute, progressive, often fatal illness appears to be related to an overall change in the virulence of group A streptococci and the reappearance of highly mucoid exotoxin-producing strains. However, the relationship between virulence factors, epidemiological features, and precise pathogenesis of these infections remains unclear. Observations: The 80% incidence of soft-tissue involvement in streptococcal toxic shock—like syndrome and the high frequency of progression to necrotizing fasciitis, myositis, or even death are unprecedented. The type and extent of tissue injury, systemic toxicity, and multiorgan system failure associated with this syndrome appear to be mediated by streptococcal pyrogenic exotoxins via the induction of biologically potent endogenous cytokines. The observed increase in the incidence and severity of invasive group A streptococcal infections coincides with the resurgence of genetically related, highly virulent strains of Staphylococcus pyogenes that express an invasive phenotype and carry a specific gene for pyrogenic exotoxin A. Conclusions: The changing spectrum of invasive group A streptococcal infections has prompted a reexamination of the microorganism and its diverse clinical manifestations. A clonal basis for increased virulence expression is supported epidemiologically. As the incidence of streptococcal toxic shock—like syndrome appears to be increasing, it is imperative that clinicians become familiar with the presentation of this syndrome so they can diagnose and treat it in a timely and effective manner.(Arch Dermatol. 1995;131:73-77) References 1. Quinn R. Comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever . Rev Infect Dis. 1989;11:928-953.Crossref 2. Veasy L, Wiedmeier S, Orsmond G, et al. Resurgence of acute rheumatic fever in the intermountain area of the United States . N Engl J Med. 1987;316:421-427.Crossref 3. Bartter T, Dascal A, Carroll K, Curley F. 'Toxic strep syndrome': a manifestation of group A streptococcal infection . Arch Intern Med. 1988;148:1421-1424.Crossref 4. Butler J, Schwartz B, Kimball J, Davis J. Severe illness associated with group A—hemolytic streptococcal infections . Wis Med J. 1991;90:525-529. 5. Cone L, Woodard D, Schlievert P, Tomory G. Clinical and bacteriologic observations of a toxic shock—like syndrome due to Streptococcus pyogenes . N Engl J Med. 1987;317:146-149.Crossref 6. Makela P, Jahkola M. Group A streptococci must be taken seriously . Finn Med J. 1989;44:418-422. 7. Margolis D, Horlick S. Group A streptococcus—induced bullous toxic shock— like syndrome . J Am Acad Dermatol. 1991;24:786-787.Crossref 8. Reid R, Briggs R, Seal D, Pearsom A. Virulent Streptococcus pyogenes: outbreak and spread within a geriatric unit . J Infect. 1983;6:219-225.Crossref 9. Ruben F, Norden C, Heisler B, Korica Y. An outbreak of Streptococcus pyogenes infections in a nursing home . Ann Intern Med. 1984;101:494-496. 10. Stevens D, Tanner M, Winship J, et al. Severe group A streptococcal infection associated with a toxic shock—like syndrome and scarlet fever toxin A . N Engl J Med. 1989;321:1-7.Crossref 11. Thomas J, Carr S, Fujioka K, Waterman S. Community-acquired group A streptococcal deaths in Los Angeles county . J Infect Dis. 1989;160:1086-1087.Crossref 12. Wood T, Potter M, Jonasson O. Streptococcal toxic shock—like syndrome: the importance of surgical intervention . Ann Surg. 1993;217:109-114.Crossref 13. Peter G, Smith A. Group A streptococcal infections of the skin and pharynx . N Engl J Med. 1977;297:311-316.Crossref 14. Wannamaker L. Differences between streptococcal infections of the throat and of the skin . N Engl J Med. 1970;282:78-85.Crossref 15. Wannamaker L. Streptococcal toxins . Rev Infect Dis. 1983;5( (suppl 4) ):S723-S732.Crossref 16. Musser J, Hauser A, Kim M. Streptococcus pyogenes causing toxic shock— like syndrome and other invasive diseases: clonal diversity and pyrogenic exotoxin expression . Proc Natl Acad Sci U S A. 1991;88:2668-2672.Crossref 17. Cleary P, Kaplan E, Handley J, et al. Clonal basis for resurgence of serious Streptococcus pyogenes disease in the 1980's . Lancet . 1992;339:518-521.Crossref 18. Schwartz B, Facklam R, Breiman R. Changing epidemiology of group A streptococcal infection in the USA . Lancet . 1990;336:1167-1171.Crossref 19. Ferrieri P. Microbiologic features of current virulent strains of group A streptococci . Pediatr Infect Dis J. 1991;10( (suppl) ):S20-S24.Crossref 20. Hensler T, Koller M, Geoffroy C, Alouf J, Konig W. Staphylococcus aureus toxic shock syndrome toxin 1 and Streptococcus pyogenes erythrogenic toxin A modulate inflammatory mediator release from human neutrophils . Infect Immun. 1993; 61:1055-1061. 21. Hackett S, Schlievert P, Stevens D. Cytokine production by human mononuclear cells in response to streptococcal exotoxins . Clin Res. 1991;39:189A. Abstract. 22. Hackett S, Stevens D. Streptococcal toxic shock syndrome: synthesis of tumor necrosis factor and interleukin-1 by monocytes stimulated with pyrogenic exotoxin A and streptolysin O . J Infect Dis. 1992;165:879-885.Crossref 23. Schlievert P. Role of superantigens in human disease . J Infect Dis. 1993;167:997-1002.Crossref 24. Mollick J, Rich R. Characterization of a superantigen from a pathogenic strain of Streptococcus pyogenes . Clin Res. 1991;39:213A. Abstract. 25. Stevens D. Invasive group A streptococcus infections . Clin Infect Dis. 1992; 14:2-13.Crossref 26. Bisno A. Streptococcus pyogenes . In: Mandell G, Douglas R, Bennett J, eds. Principles and Practice of Infectious Diseases . 3rd ed. New York, NY: Churchill Livingstone Inc; 1990:1519-1528. 27. Bradley J, Schlievert P, Sheehan P. Streptococcal toxic shock—like syndrome as a complication of primary varicella . Pediatr Infect Dis J. 1991;10:77-78.Crossref 28. Semel J. Streptococcal toxic shock syndrome following influenza A infection . Infect Dis Clin Pract. 1993;2:118-119. 29. Vuzevski V, VanJoost T, Wagenvoort J, Dey JM. Cutaneous pathology in toxic shock syndrome . Int J Dermatol. 1989;28:94-97.Crossref 30. Scott R, Naidoo J, Lightfoot N, George R. A community outbreak of group A beta-haemolytic streptococci with transferable resistance to erythromycin . Epidemiol Infect. 1989;102:85-91.Crossref 31. Breiman R, Davis J, Facklam R, et al. Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition . JAMA . 1993;269:390-391.Crossref 32. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis: the use of frozen-section biopsy . N Engl J Med. 1984;310:1689-1693.Crossref 33. Bernaldo de Quiros J, Moreno S, Munoz P, Rodriguez-Creixems M, Catalan P, Bouza E. Antigen detection in the rapid diagnosis of severe extrapharyngeal infections caused by group A streptococcus . Infect Dis Clin Pract. 1992;1:372-376. 34. Chesney PJ. Clinical aspects and spectrum of illness of toxic shock syndrome: overview . Rev Infect Dis. 1989;11( (suppl 1) ):S1-S7.Crossref 35. Gastanaduy A, Kaplan E, Huwe B, McKay C, Wannamaker L. Failure of penicillin to eradicate group A streptococci during an outbreak of pharyngitis . Lancet . 1980;2:498-502.Crossref 36. Kim K, Kaplan E. Association of penicillin tolerance with failure to eradicate group A streptococci from patients with pharyngitis . J Pediatr. 1985;107:681-684.Crossref 37. Adams E, Gudmundsson S, Yocum D, Haselby R, Craig W, Sundstrom W. Streptococcal myositis . Arch Intern Med. 1985;145:1020-1023.Crossref 38. Eagle H. Experimental approach to the problem of treatment failure with penicillin, I: group A streptococcal infection in mice . Am J Med. 1952;13:389-399.Crossref 39. Sanders E, Foster M, Scott D. Group A beta-hemolytic streptococci resistant to erythromycin and lincomycin . N Engl J Med. 1968;278:538-540.Crossref 40. Perez-Trallero E, Garcia-Arenzana J, Urbieta-Ergana M. Erythromycin resistance in streptococci . Lancet . 1989;2:444-445.Crossref 41. Witler R, Yamada S, Bass J, Hamill R, Wiebe R, Ascher D. Penicillin tolerance and erythromycin resistance of group A β-hemolytic streptococci in Hawaii and the Philippines . AJDC . 1990;144:587-589. 42. Holmstrom L, Nyman B, Rosengren M, Wallander S, Ripa T. Outbreaks of infection with erythromycin-resistant group A streptococci in child day care centres . Scand J Infect Dis. 1990;22:179-185.Crossref 43. Seppala H, Nissinen A, Jarvinen H, et al. Resistance to erythromycin in group A streptococci . N Engl J Med. 1992;326:292-297.Crossref 44. Weisblum B. Inducible resistance to macrolides, lincosamides and streptogramin type B antibiotics: the resistance phenotype, its biological diversity and structural elements that regulate expression: a review . J Antimicrob Chemother. 1985;16( (suppl A) ):63-90. 45. Gray G, Escamilla J, Hyams K, Struewing J, Kaplan E, Tupponce A. Hyperendemic Streptococcus pyogenes infection despite prophylaxis with penicillin G benzathine . N Engl J Med. 1991;325:92-97.Crossref

Journal

Archives of Dermatology – American Medical Association

Published: Jan 1, 1995

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