Objectives, Upon completion of this lecture, the student will:

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1 Lec.2 Dr.Sarmad Zeiny BCM Genus Streptococci Objectives, Upon completion of this lecture, the student will: Outline the medically important streptococci species. Classification of genus streptococci. Describing the morphology & physiology for streptococci. Determine the virulence factors for streptococci. Analyze the diseases & pathogenicity for streptococci. Demonstrate the epidemiology/transmission for streptococci. Outline the laboratory diagnosis for streptococci. State the drug of choice and prophylaxis where regularly used. 1

2 Gram positive cocci Lec.2 Dr.Sarmad Zeiny BCM Streptococci (catalase ve) Staphylococci (catalase +ve) Genus Streptococcus Fig.1: Streptococci General Characteristic: G+ve cocci, arrange in chains or pairs. (Fig.1) Some strains are capsulated, which are important in pathogenicity. Majority are facultative anaerobic, few are obligatory anaerobic. Catalase ve Non motile. Non spore forming Fastidious microorganism (require rich media for its growth with additional growth supplement). Such as Blood Agar and Chocolate Agar (enrich media). 2

3 Classification: Streptococci can be classified according to the type of hemolysis on blood agar or according to the antigenic components, both classification are used and integrated to describe member of genus Streptococci: 1. HEMOLYSIS: (tested on blood agar plate) β- hemolysis complete RBCs destruction Clear zone around the colony(called target sign) S. pyogenes, S. agalactiae α- hemolysis partial RBCs destruction Greenish discoloration of agar S.pneumoniae, Viridans streptococci γ- hemolysis No obvious changes around the colony (No hemolysis). Enterococci and non-enterococcal streptococci (S.bovis). 2. SEROLOGY (antigenic components): (Lancefield Grouping): there are differences in the polysaccharide antigens of the cell wall (C carbohydrate). Depending to these specific polysaccharide antigens, Streptococci named as groups (group specific) from A to U (more than 20 serogroups). Important are: Group A S. pyogenes Group B S. agalactiae Group D Enterococci & non-enterococcal streptococcus. Group A (S. pyogenes) have M-protein which is a type specific Ag, classify (group A) into more than (80 serotypes). M protein is a major virulence factor for the group A streptococcus. It inhibits the activation of complement and protects the organism from phagocytosis. However, it is also the weakest point in the organism's defense, because plasma cells generate antibodies against the M protein. These antibodies bind to the M protein (opsonization), aiding in the destruction of the organism by macrophages and neutrophils. So when you want to describe S. pyogenes you should say: Group A betahemolytic Streptococci =GABH Streptococci. Although there are more than 30 species of streptococci, only 5 are significant human pathogens. Three of these pathogens have Lancefield antigens: Lancefield group A, B and D. The other two pathogenic species of the streptococcal genus do not have Lancefield antigens, and are therefore just called by their species names: One is Streptococcus pneumoniae and the other is actually a big group of streptococci collectively called the Viridans group streptococci. 3

4 GROUP A β-hemolytic STREPTOCOCCI (Streptococcus pyogenes) o These organisms are so-named because they possess the Lancefield group A antigen and are beta-hemolytic on blood agar. They are also called Streptococcus pyogenes (which means pus-producing). o The components of the streptococcal cell wall that are antigenic include: C carbohydrate & M protein (~80 types). o Reservoir: Human throat Skin o Transmission: Direct contact Respiratory droplets Virulent factors & Pathogenesis: 1) M protein is a major virulence factor for the group A streptococcus. 2) Streptolysin O: The O stands for oxygen labile as it is inactivated by oxygen. This enzyme destroys red and white blood cells and is the reason for the beta-hemolytic group A streptococci's beta-hemolytic ability. This enzyme is also antigenic. Following pharyngeal or systemic beta hemolytic group A streptococcal infection, anti-streptolysin O (ASO) antibodies develop. On the wards you may order ASO titers on a patient's blood to confirm recent infection. 3) Streptolysin S: The S stands for oxygen stabile. This is also responsible for beta-hemolysis but is not antigenic. 4) Pyrogenic exotoxin (also called erythrogenic toxin): This is found in only a few strains of beta hemolytic group A streptococci, but when these strains invade they can cause scarlet fever. Some strains produce pyrogenic exotoxins that are superantigens. The exotoxins directly super stimulate T cells to pour out inflammatory cytokines, this is called streptococcal toxic shock syndrome 5) Streptokinase (activates the proteolytic enzyme plasmin, which breaks up fibrin blood clots). spreading factor 6) Hyaluronidase spreading factor 7) Streptodornases (DNAases) spreading factor 8) (Anti-C5a) peptidase. anti-inflammatory 4

5 Diseases: I. Local infections(invasion): 1) Sore throat (acute pharyngitis, pharyngotonsillitis). 2) Wound infection, cellulitis, Necrotizing fasciitis and myonecrosis. 3) Impetigo. 4) Erysipelas (erythema on face). II. Systemic infection: (invasion &/or toxin) 1) Sepsis. 2) Meningitis. 3) Puerperal sepsis. 4) Streptococcus toxic shock syndrome, Scarlet fever (sunburn rash) both caused by pyrogenic exotoxins. III. Post streptococcal infection sequel ( delayed antibody mediated diseases): it is a non-suppurative complications 1) Rheumatic fever (after sore throat): type II hypersensitivity 2) Acute glomerulonephritis (after skin or pharynx infection), mainly by M-12 serotype: type III hypersensitivity Notes on post streptococcal infection sequel: Rheumatic fever: It usually strikes children 5-15 years of age. When it occurs, it has been shown to follow untreated beta-hemolytic group A streptococcal pharyngitis (but NOT after a skin infection). Rheumatic fever is antibody-mediated. There are antigens in the heart that are similar to the antigens of the beta-hemolytic group A streptococci. Therefore, the antibodies that forms to eradicate this particular streptococcus also cross-react with antigens in the heart. This immunologic attack on the heart tissue causes heart inflammation, called myocarditis. Patients may complain of chest pain and may develop arrhythmias or heart failure. ASO test: Measure Ab against Streptolysin O, ASO test used in suspected case of rheumatic fever. This test used to determine significance of current streptococcal infection by measuring the ASOT: ASOT (Ab Titer): Normal < 200 > significance result 5

6 Acute post-streptococcal glomerulonephritis: This is an antibody-mediated inflammatory disease of the glomeruli of the kidney. It occurs about one week after infection of either the pharynx OR skin by nephritogenic (having the ability to cause glomerulonephritis) strains of betahemolytic group A streptococci. Certain antigens from these nephritogenic streptococci induce an antibody response. The resulting antigen-antibody complexes travel to and are deposited in the glomerular basement membrane, where they activate the complement cascade. This leads to local glomerular destruction in the kidney. Lab Dx for S.pyogenes: Specimens: depend on the nature of infection, e.g. sputum, throat swab, nasopharyngeal swab, blood, CSF etc. Gram stain: G+ve cocci, arrange in chains. Culture: on blood agar under 5-10%CO 2 pinpointed, Grayish white, translucent, matte or glossy colonies with large zone of β- hemolysis. Sensitive to Bacitracin disc (0.04 U) causes zone of growth inhibition more than 15mm. PYR +ve: rapid test, pink is positive. Serology: 1)The rapid strep test (ELISA-based), 2) Lancefield grouping, 3) M- protein serotyping and 4) ASO test: Ab Titer: Normal < 200 > significance result GROUP B STREPTOCOCCI S. agalactiae (β- hemolytic, Group B) Normal flora of female genital tract (15-25% of woman), male urethra. Leading Cause for neonatal sepsis, pneumonia & meningitis (acquire these bacteria during delivery). Pathogenesis: Capsule, hemolysin and camp factor These streptococci are also beta-hemolytic. When thinking of group B streptococci, think of group B for BABY. Bacitracin resistant. Hydrolyzes hippurate. Positive (purple color) camp test-positive: camp factor is a polypeptide that "compliments" a Staph aureus to make an area of new complete beta-hemolysis. Organism produces definitive arrow when close to Staphylococcus aureus. 6

7 GROUP D STREPTOCOCCI (Enterococci and Non-enterococci) Enterococci Non-Enterococci Enterococcus faecalis Enterococcus faecium Streptococcus bovis Streptococcus equinus Enterococcus (E.faecalis, E.faecium): Normal flora of GIT, oral mucosa. Grow well in 40% bile and on 6.5% NaCl. Causes UTI, biliary tract infection, and endocarditis. Varies Hemolysis PYR +ve Hydrolyzes esculin in 40% bile and 6.5% NaCl (bile esculin agar turns black). Vancomycin resistant enterococci (VRE) have developed and have been spreading. Treatment as with VRSA. Non-enterococcus (Streptococcus bovis, Streptococcus equinus ): Like the enterococci, Streptococcus bovis is hardy, growing in 40% bile (but not in 6.5% NaCl). It lives in the G.I. tract, and it causes similar diseases. An important unique property is that there is a remarkable association between S. bovis infection and colon cancer!!! In some series 50% of people with S. bovis bacteremia have a colonic malignancy. We do not know if S. bovis is a cause of colon cancer or just a marker of the disease. (BOVIS in the BLOOD: Better Beware, CANCER in the BOWEL) 7

8 Summary: Streptococci classified according to the type of hemolysis & antigenic components. S.pyogenes is the most pathogenic species because of their virulent factors. S.pyogenes can cause post-infection severe complications. ASO test used in suspected case of rheumatic fever. Streptococci easily diagnosed in the lab. By using Gram s staining, culture and biochemical tests. S.agalactia is the leading Cause for neonatal sepsis, pneumonia & meningitis. Enterococcus Causes UTI, biliary tract infection, wound infection, bed sore, endocarditis. streptococci infections can be prevented by regular hygiene precautions and by antibiotics, no vaccine. References: - Review of Medical Microbiology and Immunology11th edition Clinical Microbiology Made Ridiculously Simple, 6 th ed, Baily & Scott diagnostic microbiology, 12 th ed. - Lippincotts Illustrated microbiology 3 ed ed., 2013 END 8