Group A Streptococcus (GAS)

InfectionBlok 26

Objective

Provide overview about diseases caused by Group A Streptoccous (GAS) Highlights on suppurative infection especially

Streptococcal faringits

At a glance for non-suppurative

Introduction Group A Streptococcus (GAS) or Streptococcus pyogenes

Leading pathogenic bacteria

Infects children and adolescent

Wide spectrum of infection and disease state benign till life-threatning

Worldwild annually > 600 million case of strep throat

> 100 million case of GAS pyoderm

Also potential to produce delayed non suppurative sequelae (PSAGN, ARF, PSRA)

Despite the beneficial effects of antibiotics clinicians continue to encounter GAS disease frequently in practice.

GAS Virulece factors :

Protein F

Protein M

Capsul

C5a peptidase

Streptolysin S

Streptolysin O

Streptococcus Pyrogenic Exotoxin (SPE)

Hyaluronidase

Streptokinase

DNAase A,B,C,D

etc

Virulence factors >> wide spectrum of clincal manifestation

Mechanism : Suppuration

Toxin elaboration

Immune-mediated inflammation

Clinical ManifestaionSuppurative

Pharyngitis

Scarlet fever

Impetigo

Eryseplas

Celullitis

Necrotizin fascitis

STSS

Pneumonia

ets

Non-suppurative

Rheumatic Fever

GNAPS

Certain psoriasi

Pharyngitis Upper Respiratory Infection

Largest contribution on antibiotic usage

Difficult to differentiate bacterial or viral

Strept throat 15-20% in children, especially above 5 years

Incubation 2-4 days

Sore throat, swallowing pain, fever, malaise, nausea, abdominal pain

Physical examination Edematous and

hyperemic pharynx

Hypertrophy tonsil, hyperemic, occasionally with yellowish or greyish exudate

Ptechiae and red punctate in palatal area (forscheimer spot)

Painful anterior cervical lymphadenopathy

Diangosis Culutre

RADT

Not common in developing country

Clinical diffculut, overlapping between GAS and non GAS

Differential Diagnosis Bacterial, Viral, Mycoplasma, Chlamidya

Clinical manifestation for suggestive streptococcal and

viral pharygitisGAS

Acute sore throat

Age 5-15 years old

Fever

Headache

Nausea, vomiting, and abdominal pain

Inflammation signs at tonsil and pharynx area

Exudate at tonsil and pharynx area

Ptechiae at palatatl area

History of contact with streptococcal pharyngitas patient

Scarlatiniform rash

Viral

Conjunctivitis

Cough

Coryza

Diarrhea

Hoarse voice

Discrete Ulcerative Stomatitis

Viral exanthems rash

Medication Can be self-limited

Antibiotic : Decrease duration of illness

Reduce contagious period

Reduce the incidence of complication

First line : Penicillin or Amoxicillin 50 mg/kg/day for 10 days

Allergic to penicillin

Cefadroxil 30 mg/kg/day 10 days

Clindamyycin 15 mg/kd/day 10 days

Azithromycin 10 mg/kg/day 5 days

Scarlet Fever Disease in children

10% strept throat scarlet fever

Incubation : 12 hours – 5 days

Fever, headache, vomiting, and abdominal pain

After 1-2 days fine-grade sandpaper, from neck and upper trunk whole body and extremities, rarely spread to palms

Occasionally with pruritus, pain (-)

Obvious rash at flexor area with pastia signs

After 3-4 days desquamation

Flushing face with circumoral pallor

Edematous and hyperemic pharyx

Hypertrophy and hyperemic tonsil with yellowish/greyish exudate

Tongue Tongue coated

with white membrane and hypertrophy papilla (white strawberry tongue)

After 2 days desquamation on white membrane strawberry tongue

Diagnosis Clinical maifestation

RADT

Swab culture

Treatment Penicillin class or erythromycin for 10 days

Complication : abscess, sinusitis, pneumonia, meningitis, and rheumatic fever

Impetigo Epidermal infection

Yellowish crust above hyperemic skin

Small papule vesicle pustule yellowish curust (honey-colored crust)

Systemic sign (-)

Strain with virulence factor M 49 corerlates with PSAGN

Therapy topical muporicin

Erysipelas Skin infecton that affects

dermis and lymph vascular system

Common etiology : GAS

Predilection area : lower extremities and face

Acute infection : Erythematous skin, pain,

edema with distinct border

Red lines which cross lesion border

Fever

Cellulitis Progressive acute skin

inflammation on dermis and subcutaneous tissue

Undemarcated border, erythematous skin, induration (+), fluctuation, crepitation, erosion, or bullae.

Regional lympadenopahty

Pain on infected site

Necrotizing Fasciitis Acute and very

progressif infection subcutaneous tissue till fascia and muscles

Erythematous lesion 24-48 hours purple with hemorrhagic bullae necrotic and gangrene expose of tendon and muscles

Incidence followe after minor trauma or muscle strain

Antibiotic and debridement

Streptococcal Toxic Shock Syndrome

Inflammation respond fever, rash, hypotension, and multi organ dysfunction

Related to SPEA

Happen after any site of infection

80% proceeds with skin infection at lower limb

Diagnostic criteria (The working group of Sever Streptococcal Infection 1993) A. Isolation GAS form

Sterile site

Non sterile site

B. Clinical manifestaton

1. Hypotension

2. Other severe clinical disoreder (2 or more)

Renal disorder

Coagulopathy

Liver disorder

Respiratory distress

Soft tissue necrosis

Erymathous macular rash with desquamation

Definiitve case A1, B1, and B2

Probable case A2, B1, and B3

Treatment Antibiotic

Admission in ICU

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