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Kim TH. Toxic Shock Syndrome (TSS) Caused by Group A Streptococcus: Novel Insights Within the Context of a Familiar Clinical Syndrome. J Korean Med Sci 2024; 39:e154. [PMID: 38711318 DOI: 10.3346/jkms.2024.39.e154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024] Open
Abstract
The emergence of invasive infections attributed to group A Streptococcus (GAS) infections, has resurged since the 1980s. The recent surge in reports of toxic shock syndrome due to GAS in Japan in 2024, while sensationalized in the media, does not represent a novel infectious disease per se, as its diagnosis, treatment, and prevention are already well-established. However, due to signs of increasing incidence since 2011, further research is needed. Health authorities in neighboring countries like The Republic of Korea should not only issue travel advisories but also establish meticulous surveillance systems and initiate epidemiological studies on the genotypic variations of this disease while awaiting various epidemiological research findings from Japan.
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Affiliation(s)
- Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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2
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Mercadante S, Ficari A, Romani L, De Luca M, Tripiciano C, Chiurchiù S, Calo Carducci FI, Cursi L, Di Giuseppe M, Krzysztofiak A, Bernardi S, Lancella L. The Thousand Faces of Invasive Group A Streptococcal Infections: Update on Epidemiology, Symptoms, and Therapy. CHILDREN (BASEL, SWITZERLAND) 2024; 11:383. [PMID: 38671600 PMCID: PMC11048970 DOI: 10.3390/children11040383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Invasive infections caused by Streptococcus pyogfenes (iGAS), commonly known as Group A Streptococcus, represent a significant public health concern due to their potential for rapid progression and life-threatening complications. Epidemiologically, invasive GAS infections exhibit a diverse global distribution, affecting individuals of all ages with varying predisposing factors. The pathogenesis of invasive GAS involves an array of virulence factors that contribute to tissue invasion, immune evasion, and systemic dissemination. In pediatrics, in the last few years, an increase in iGAS infections has been reported worldwide becoming a challenging disease to diagnose and treat promptly. This review highlights the current knowledge on pathogenesis, clinical presentations, and therapeutic approaches for iGAS in children.
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Affiliation(s)
- Stefania Mercadante
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrea Ficari
- Residency School of Pediatrics, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Costanza Tripiciano
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Sara Chiurchiù
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Francesca Ippolita Calo Carducci
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Cursi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Martina Di Giuseppe
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrzej Krzysztofiak
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Stefania Bernardi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Lancella
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
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3
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Wang Y, Ahmadi MZ, Dikeman DA, Youn C, Archer NK. γδ T cell-intrinsic IL-1R promotes survival during Staphylococcus aureus bacteremia. Front Immunol 2023; 14:1171934. [PMID: 37483624 PMCID: PMC10361057 DOI: 10.3389/fimmu.2023.1171934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Staphylococcus aureus is a leading cause of bacteremia, further complicated by the emergence of antibiotic-resistant strains such as methicillin-resistant S. aureus (MRSA). A better understanding of host defense mechanisms is needed for the development of host-directed therapies as an alternative approach to antibiotics. The levels of IL-1, IL-17, and TNF-α cytokines in circulation have been associated with predictive outcomes in patients with S. aureus bacteremia. However, their causative role in survival and the cell types involved in these responses during bacteremia is not entirely clear. Using a mouse model of S. aureus bacteremia, we demonstrated that IL-17A/F and TNF-α had no significant impact on survival, whereas IL-1R signaling was critical for survival during S. aureus bacteremia. Furthermore, we identified that T cells, but not neutrophils, monocytes/macrophages, or endothelial cells were the crucial cell type for IL-1R-mediated survival against S. aureus bacteremia. Finally, we determined that the expression of IL-1R on γδ T cell, but not CD4+ or CD8+ T cells was responsible for survival against the S. aureus bacteremia. Taken together, we uncovered a role for IL-1R, but not IL-17A/F and TNF-α in protection against S. aureus bacteremia. Importantly, γδ T cell-intrinsic expression of IL-1R was crucial for survival, but not on other immune cells or endothelial cells. These findings reveal potential cellular and immunological targets for host-directed therapies for improved outcomes against S. aureus bacteremia.
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Affiliation(s)
| | | | | | | | - Nathan K. Archer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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4
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Patel T, Quow K, Cardones AR. Management of Infectious Emergencies for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2021; 10:232-242. [PMID: 34642610 PMCID: PMC8493951 DOI: 10.1007/s13671-021-00334-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 12/20/2022]
Abstract
Purpose of Review There are various dermatologic emergencies stemming from bacterial, viral, and fungal etiologies that can present in the inpatient setting. This review summarizes the pathogenesis and diagnosis of infections with cutaneous involvement and highlights new therapies. Recent Findings Clindamycin inhibits toxin formation and can be used as an adjunct therapy for the staphylococcal scalded syndrome. Isavuconazole therapy for mucormycosis infection is a less toxic alternative to amphotericin B. Summary Diagnosis of these infections is primarily guided by high clinical suspicion and early recognition can prevent dangerous sequelae. Treatment mainstays have been well-established, but there are adjunctive therapies that may potentially benefit the patient.
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Affiliation(s)
- Tulsi Patel
- Duke University School of Medicine, Durham, NC 27710 USA
| | - Krystina Quow
- Department of Dermatology, Duke University, Durham, NC 27710 USA
| | - Adela R Cardones
- Department of Dermatology, Duke University, Durham, NC 27710 USA
- Durham VA Medical Center, Durham, NC 27705 USA
- Durham, USA
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5
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Osowicki J, Azzopardi KI, Fabri L, Frost HR, Rivera-Hernandez T, Neeland MR, Whitcombe AL, Grobler A, Gutman SJ, Baker C, Wong JMF, Lickliter JD, Waddington CS, Pandey M, Schuster T, Cheng AC, Pollard AJ, McCarthy JS, Good MF, Dale JB, Batzloff M, Moreland NJ, Walker MJ, Carapetis JR, Smeesters PR, Steer AC. A controlled human infection model of Streptococcus pyogenes pharyngitis (CHIVAS-M75): an observational, dose-finding study. THE LANCET MICROBE 2021; 2:e291-e299. [PMID: 35544165 DOI: 10.1016/s2666-5247(20)30240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes is a leading cause of infection-related morbidity and mortality. A reinvigorated vaccine development effort calls for new clinically relevant human S pyogenes experimental infection models to support proof of concept evaluation of candidate vaccines. We describe the initial Controlled Human Infection for Vaccination Against S pyogenes (CHIVAS-M75) study, in which we aimed to identify a dose of emm75 S pyogenes that causes acute pharyngitis in at least 60% of volunteers when applied to the pharynx by swab. METHODS This observational, dose-finding study was done in a clinical trials facility in Melbourne (VIC, Australia). Groups of healthy volunteers aged 18-40 years, at low risk of complicated S pyogenes disease, and without high type-specific anti-emm75 IgG antibodies against the challenge strain were challenged and closely monitored as inpatients for up to 6 days, and then as outpatients for 6 months. Antibiotics were started upon diagnosis (clinical signs and symptoms of pharyngitis and a positive rapid molecular test) or after 5 days in those without pharyngitis. Rapid test results were confirmed by standard bacterial culture. After a sentinel participant, cohorts of five and then ten participants were challenged, with protocol-directed dose-escalation or de-escalation for subsequent cohorts. The primary outcome was the proportion of participants at each dose level with pharyngitis by day 5 after challenge. The study is registered with ClinicalTrials.gov, NCT03361163. FINDINGS Between July 10, 2018, and Sept 23, 2019, 25 healthy adults were challenged with emm75 S pyogenes and included in analyses. Pharyngitis was diagnosed in 17 (85%; 95% CI 62-97) of 20 participants at the starting dose level (1-3 × 105 colony-forming units [CFU]/mL). This high proportion prompted dose de-escalation. At the lower dose level (1-3 × 104 CFU/mL), pharyngitis was diagnosed in one of five participants. Immunological, biochemical, and microbiological results supported the clinical picture, with acute symptomatic pharyngitis characterised by pharyngeal colonisation by S pyogenes accompanied by significantly elevated C-reactive protein and inflammatory cytokines (eg, interferon-γ and interleukin-6), and modest serological responses to streptolysin O and deoxyribonuclease B. There were no severe (grade 3) or serious adverse events related to challenge. INTERPRETATION We have established a reliable pharyngitis human infection model with reassuring early safety findings to accelerate development of vaccines and other interventions to control disease due to S pyogenes. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia.
| | - Kristy I Azzopardi
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Loraine Fabri
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Hannah R Frost
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tania Rivera-Hernandez
- Unidad de Investigación Médica en Inmunoquímica, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico; School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Melanie R Neeland
- Epigenetics Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Alana L Whitcombe
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Sarah J Gutman
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Imaging Research, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ciara Baker
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | | | | | - Claire S Waddington
- Department of Medicine, University of Cambridge, Cambridge, UK; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Manisha Pandey
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - James S McCarthy
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia; QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Michael F Good
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - James B Dale
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michael Batzloff
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Nicole J Moreland
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Pierre R Smeesters
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
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Abstract
Necrotizing soft tissue infections occur after traumatic injuries, minor skin lesions, nonpenetrating injuries, natural childbirth, and in postsurgical and immunocompromised patients. Infections can be severe, rapidly progressive, and life threatening. Survivors often endure multiple surgeries and prolonged hospitalization and rehabilitation. Despite subtle nuances that may distinguish one entity from another, clinical approaches to diagnosis and treatment are highly similar. This review describes the clinical and laboratory features of necrotizing soft tissue infections and addresses recommended diagnostic and treatment modalities. It discusses the impact of delays in surgical debridement, antibiotic use, and resuscitation on mortality, and summarizes key pathogenic mechanisms.
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Affiliation(s)
- Dennis L Stevens
- Infectious Diseases Center of Biomedical Research Excellence, Veterans Affairs Medical Center, 500 West Fort Street (Mail Stop 151), Boise, ID 83702, USA
| | - Amy E Bryant
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA.
| | - Ellie Jc Goldstein
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90074, USA; R M Alden Research Laboratory, 2021 Santa Monica Boulevard, Suite #740 East, Santa Monica, CA 90404, USA
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7
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Davis KL, Gonzalez O, Kumar S, Dick EJ. Pathology Associated With Streptococcus spp. Infection in Baboons ( Papio spp.). Vet Pathol 2020; 57:714-722. [PMID: 32744146 DOI: 10.1177/0300985820941496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Streptococcus spp. are a source of morbidity and mortality in captive nonhuman primate populations. However, little is known about the lesions associated with naturally occurring streptococcal infections in baboons (Papio spp.). The pathology database of the Southwest National Primate Research Center was searched for all baboon autopsies from 1988 to 2018 in which Streptococcus spp. were cultured. Baboons on experimental protocol were excluded. The gross autopsy and histopathology reports were reviewed. Archived specimens were retrieved and reviewed as needed for confirmation or clarification. Fifty-six cultures were positive for Streptococcus spp. in 54 baboons with evidence of bacterial infection. Associated gross lesions included purulent exudate, fibrinous to fibrous adhesions, hemorrhage, mucosal thickening, organomegaly, and abscessation. Histologic lesions included suppurative inflammation, abscessation, necrosis, hemorrhage, fibrin accumulation, and thrombosis. Lungs and pleura (n = 31) were the most commonly infected organ followed by the central nervous system (n = 16), spleen (n = 15), soft tissues (n = 12), air sacs, liver, peritoneum, adrenal glands, heart, lymph nodes, uterus, kidneys, biliary system, bones, ears, umbilical structures, mammary glands, pancreas, placenta, and salivary glands. Infections by non-β-hemolytic Streptococcus spp. predominated in the lungs and air sacs; the most common isolate was Streptococcus pneumoniae. Infections by β-hemolytic Streptococcus spp. predominated in the soft tissues and reproductive tract. Naturally occurring β-hemolytic and non-β-hemolytic Streptococcus spp. infections cause morbidity and mortality in captive baboon populations. The lesions associated with streptococcal infection are similar to those reported in human infection. Thus, the baboon may represent an underutilized model for studying Streptococcus spp. as pathogens.
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Affiliation(s)
- Katelin L Davis
- 311308Purdue University, West Lafayette, IN, USA.,National Cancer Institute, Bethesda, MD, USA
| | - Olga Gonzalez
- Southwest National Primate Research Center, San Antonio, TX, USA
| | - Shyamesh Kumar
- Southwest National Primate Research Center, San Antonio, TX, USA
| | - Edward J Dick
- Southwest National Primate Research Center, San Antonio, TX, USA
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Liu YH, Wu PH, Kang CC, Tsai YS, Chou CK, Liang CT, Wu JJ, Tsai PJ. Group A Streptococcus Subcutaneous Infection-Induced Central Nervous System Inflammation Is Attenuated by Blocking Peripheral TNF. Front Microbiol 2019; 10:265. [PMID: 30837977 PMCID: PMC6389723 DOI: 10.3389/fmicb.2019.00265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/01/2019] [Indexed: 11/13/2022] Open
Abstract
Group A streptococcus (GAS) infection causes a strong inflammatory response associated with cytokine storms, leading to multiorgan failure, which is characterized as streptococcal toxic shock syndrome. However, little is known about GAS subcutaneous infection-mediated brain inflammation. Therefore, we used a bioluminescent GAS strain and reporter mice carrying firefly luciferase under transcriptional control of the nuclear factor-kappa B (NF-κB) promoter to concurrently monitor the host immune response and bacterial burden in a single mouse. Notably, in addition to the subcutaneous inoculation locus at the back of mice, we detected strong luminescence signals from NF-κB activation and increased inflammatory cytokine production in the brain, implying the existence of central nervous system inflammation after GAS subcutaneous infection. The inflamed brain exhibited an increased expression of glial fibrillary acidic protein and nicotinamide adenine dinucleotide phosphate oxidase components and greater microglial activation and blood–brain barrier (BBB) disruption. Furthermore, Fluoro-Jade C positive cells increased in the brain, indicating that neurons underwent degeneration. Peripheral tumor necrosis factor (TNF), which contributes to pathology in brain injury, was elevated in the circulation, and the expression of its receptor was also increased in the inflamed brain. Blockage of peripheral TNF effectively reduced brain inflammation and injury, thereby preventing BBB disruption and improving survival. Our study provides new insights into GAS-induced central nervous system inflammation, such as encephalopathy, which can be attenuated by circulating TNF blockage.
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Affiliation(s)
- Ya-Hui Liu
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Hua Wu
- Department of Medical Laboratory Science and Biotechnology, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Cheng Kang
- Department of Medical Laboratory Science and Biotechnology, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Sheng Tsai
- Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan.,Research Center of Clinical Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chuan-Kai Chou
- National Laboratory Animal Center, National Applied Research Laboratories, Taipei, Taiwan
| | - Chung-Tiang Liang
- Novo Nordisk Research Centre China, Beijing, China.,Department of Animal Facility, Discovery Biology China, Beijing, China
| | - Jiunn-Jong Wu
- Department of Medical Laboratory Science and Biotechnology, Medical College, National Cheng Kung University, Tainan, Taiwan.,Department of Biotechnology and Laboratory Science in Medicine, School of Biomedical Science and Engineering, National Yang-Ming University, Taipei, Taiwan
| | - Pei-Jane Tsai
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medical Laboratory Science and Biotechnology, Medical College, National Cheng Kung University, Tainan, Taiwan.,Research Center of Infectious Disease and Signaling, National Cheng Kung University, Tainan, Taiwan
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9
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Yoshizawa S, Matsumura T, Ikebe T, Ichibayashi R, Fukui Y, Satoh T, Tsubota T, Honda M, Ishii Y, Tateda K, Ato M. Streptococcal toxic shock syndrome caused by β-hemolytic streptococci: Clinical features and cytokine and chemokine analyses of 15 cases. J Infect Chemother 2019; 25:355-361. [PMID: 30744988 DOI: 10.1016/j.jiac.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/28/2018] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES β-Hemolytic streptococci occasionally cause severe infections such as necrotizing fasciitis and streptococcal toxic shock syndrome (STSS). Here, we conducted a prospective study to investigate the production of cytokines and chemokines in patients with STSS to explore its pathogenesis in survivors and fatal cases. METHODS From January 2013 through August 2015, all culture results from normally sterile sites were prospectively followed and screened for STSS. Clinical characteristics of the patients with STSS were evaluated and compared between survivors and fatal cases. Serum samples were collected on admission for quantification of various cytokines and chemokines. Bacterial strains were categorized by Lancefield grouping and analyzed for the emm type, and presence of speA, speB, speC, and speF. RESULTS Fifteen patients received diagnosis of STSS. The median age of the patients was 60-year-old, and the mortality rate was 40% despite intensive treatment. Nine strains were categorized as group A, two belonged to group G, and four to group B. Group A contained various emm genotypes. Unexpectedly, potent proinflammatory cytokine levels such as TNF-α and IL-1β were not significantly elevated, and comparison with surviving patients showed that IL-6, IL-8, and MCP-1 levels were significantly decreased and creatine kinase level was significantly elevated in fatally ill cases. CONCLUSION Our results indicate that reduced production of proinflammatory cytokines and chemokines may be involved in STSS pathogenesis and critical for prognosis of patients with STSS.
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Affiliation(s)
- Sadako Yoshizawa
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Takayuki Matsumura
- Department of Immunology, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, 162-8640, Tokyo, Japan
| | - Tadayoshi Ikebe
- Department of Bacteriology I, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, 162-8640, Tokyo, Japan
| | - Ryo Ichibayashi
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Yuto Fukui
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Takahiro Satoh
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Takaya Tsubota
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Mitsuru Honda
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Yoshikazu Ishii
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Kazuhiro Tateda
- Toho University School of Medicine, 5-21-16 Omori-nishi, Ota-ku, 143-8540, Tokyo, Japan
| | - Manabu Ato
- Department of Immunology, National Institute of Infectious Diseases, 1-23-1 Toyama, Shinjuku-ku, 162-8640, Tokyo, Japan.
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10
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11
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WHO/IVI global stakeholder consultation on group A Streptococcus vaccine development: Report from a meeting held on 12–13 December 2016. Vaccine 2018; 36:3397-3405. [DOI: 10.1016/j.vaccine.2018.02.068] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/02/2018] [Accepted: 02/16/2018] [Indexed: 12/21/2022]
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12
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Zavala S, Arias M, Legua P. Fulminant streptococcal toxic shock syndrome. J R Coll Physicians Edinb 2018; 48:33-35. [DOI: 10.4997/jrcpe.2018.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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Benvenuti M, An T, Amaro E, Lovejoy S, Mencio G, Martus J, Mignemi M, Schoenecker JG. Double-Edged Sword: Musculoskeletal Infection Provoked Acute Phase Response in Children. Orthop Clin North Am 2017; 48:181-197. [PMID: 28336041 DOI: 10.1016/j.ocl.2016.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The acute phase response has a crucial role in mounting the body's response to tissue injury. Excessive activation of the acute phase response is responsible for many complications that occur in orthopedic patients. Given that infection may be considered continuous tissue injury that persistently activates the acute phase response, children with musculoskeletal infections are at markedly increased risk for serious complications. Future strategies that modulate the acute phase response have the potential to improve treatment and prevent complications associated with musculoskeletal infection.
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Affiliation(s)
| | - Thomas An
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Emilie Amaro
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Steven Lovejoy
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA; Departments of Orthopaedics, Pharmacology, and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.
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14
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Stevens DL, Aldape MJ, Bryant AE. Necrotizing Fasciitis, Gas Gangrene, Myositis and Myonecrosis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00011-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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15
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Sepehri Z, Masoumi M, Ebrahimi N, Kiani Z, Nasiri AA, Kohan F, Sheikh Fathollahi M, Kazemi Arababadi M, Asadikaram G. Atorvastatin, Losartan and Captopril Lead to Upregulation of TGF-β, and Downregulation of IL-6 in Coronary Artery Disease and Hypertension. PLoS One 2016; 11:e0168312. [PMID: 28033321 PMCID: PMC5199082 DOI: 10.1371/journal.pone.0168312] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 11/30/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction Coronary artery disease (CAD) and hypertension are the main reasons of ischemic heart diseases (IHDs). Cytokines as the small glycoproteins are the main arm of immune system and manipulate all of the cardiovascular diseases. The aim of the current study was to examine the effects of treatment of hypertension and CAD on serum levels of IL-6, IL-8, TGF-β and TNF-α. Material and Methods This interventional study was performed on the patients with hypertension without CAD (group 1), hypertension and CAD (group 2), CAD but not hypertension (group 3) and without hypertension and CAD as controls (group 4). The patients received routine treatment for hypertension and CAD. Serum levels of IL-6, IL-8, TGF-β and TNF-α were analyzed in the groups treated with various drugs, using ELISA technique. Results With regard to the medications, Atorvastatin, Losartan and Captopril were administered more in patients (groups 1, 2 and 3) than the patients without hypertension and CAD. The results revealed that serum levels of TGF-β and IL-6 were significantly increased and decreased, respectively, in the groups 1, 2 and 3 when compared to group 4. Serum levels of TGF-β were also increased in females in comparison to males in the group 4. Discussion According to the results it seems that Atorvastatin, Losartan and Captopril have reduced inflammation in in vivo conditions via downregulation of IL-6 and upregulation of TGF-β.
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Affiliation(s)
- Zahra Sepehri
- Department of Internal Medicine, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Mohammad Masoumi
- Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
- * E-mail: ,
| | - Nazanin Ebrahimi
- Department of Biochemistry, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Zohre Kiani
- Student Research Committee, Zabol University of Medical Sciences, Zabol, Iran
- Department of Internal Medicine, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Akbar Nasiri
- Department of Anesthesiology, Zabol University of Medical Sciences, Zabol, Iran
| | - Farhad Kohan
- Student Research Committee, Zabol University of Medical Sciences, Zabol, Iran
| | - Mahmood Sheikh Fathollahi
- Immunology of Infectious Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Department of Social Medicine, Faculty of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Mohammad Kazemi Arababadi
- Immunology of Infectious Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
- Department of Laboratory Sciences, Faculty of Paramedicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Gholamreza Asadikaram
- Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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16
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Abstract
Septic cardiomyopathy is a severe complication among some patients who develop group A streptococcal toxic shock syndrome. Despite the importance of cardiac dysfunction in determining prognosis, very little is known about mechanisms that reduce cardiac output in association with streptococcal infection. Here, we investigated the effects of streptococcal extracellular toxins on mechanical contractility of electrically paced primary murine cardiomyocytes. Our data demonstrate that streptolysin O (SLO) is the major streptococcal toxin responsible for cardiomyocyte contractile dysfunction. Streptolysin O dose-dependently affected cardiac myocyte function in discrete stages. Exposure to SLO caused a failure of cardiac cells to respond to electrical pacing, followed by spontaneous dysregulated contractions and augmented strength of contraction. Central to these SLO-mediated effects is a marked influx of calcium into the cytosol through SLO-mediated pores in the cytoplasmic membrane. Such calcium mobilization in response to SLO correlated temporally with hypercontractility and unpaced contractions. During continued exposure to SLO, cardiomyocytes exhibited periods of reversion to normal electrical pacing suggestive of membrane lesion repair and restoration of calcium handling. Together, these observations are consistent with the clinical observation that septic cardiomyopathy is a reversible condition in patients who survive streptococcal toxic shock syndrome. These data provide strong evidence that streptococcal exotoxins, specifically SLO, can directly impact cardiac mechanical function.
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17
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Morefield G, Touhey G, Lu F, Dunham A, HogenEsch H. Development of a recombinant fusion protein vaccine formulation to protect against Streptococcus pyogenes. Vaccine 2014; 32:3810-5. [DOI: 10.1016/j.vaccine.2014.04.092] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 04/22/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
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18
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Li Z, Bryant AE, Hamilton SM, Bayer CR, Ma Y, Stevens DL. Do cardiomyocytes mount an immune response to Group A Streptococcus? Cytokine 2011; 54:258-65. [PMID: 21377378 DOI: 10.1016/j.cyto.2011.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Revised: 12/02/2010] [Accepted: 02/03/2011] [Indexed: 12/30/2022]
Abstract
Some patients with Group A Streptococcal toxic shock syndrome (StrepTSS) develop a unique form of cardiomyopathy characterized by global hypokinesia and reduced cardiac index. Here we investigated the immune responses of cardiomyocytes to Group A Streptococcus both in vivo and in vitro. Our data demonstrate that cardiomyocyte-derived cytokines are produced following both direct GAS stimulation and after exposure to GAS-activated inflammatory cells. These locally produced, cardiomyocyte-derived cytokines may mediate cardiac contractile dysfunction observed in patients with StrepTSS-associated cardiomyopathy and may hold the key to our ability to attenuate this severe complication.
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Affiliation(s)
- Zhi Li
- Infectious Diseases Section, Veterans Affairs Medical Center, Boise, ID 83702, USA.
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19
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Abstract
Three types of group A streptococcal infections are particularly feared: necrotizing fasciitis, myositis, and streptococcal toxic shock syndrome (TSS). We present 3 cases of necrotizing fasciitis due to Streptococcus pyogenes, one in an immunocompromised patient who had received kidney transplant and 2 healthy patients. Mean age of patients was 52 years (range, 42-67 years), and all 3 were male. One spontaneous case in absence of any obvious portal of entry is reported. The clinical course was initially indolent but quickly destructive. All patients required emergency surgical debridement and intravenous antibiotics. In 2 cases, intravenous immunoglobulin therapy was added. Differential diagnoses include septic arthritis, cellulitis, gout, other causes of tenosynovitis, erysipelas, and deep vein thrombosis.Blood and soft-tissue cultures should be obtained to identify the bacteria, and emergency computed tomography or magnetic resonance imaging scan should be performed to confirm the diagnosis and define the extension of the necrosis. Aggressive surgical debridement in the first 24 to 48 hours and antibiotic treatment, including penicillin and clindamycin, are the cornerstones in the management of these infections. Adjuvant intravenous immunoglobulin therapy might be useful in case of TSS. Diagnostic and treatment delays are the main causes of mortality in these infections.
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20
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Stevens DL, Aldape MJ, Bryant AE. Necrotizing fasciitis, gas gangrene, myositis and myonecrosis. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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21
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Holub M, Helcl M, Beran O, Hnyková J, Príhodová J. Kinetics of Immune Parameters in a Patient with Sepsis Caused by Streptococcus pyogenes Treated with Activated Protein C. ACTA ACUST UNITED AC 2009; 36:485-8. [PMID: 15307574 DOI: 10.1080/00365540410016113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report a case of streptococcal sepsis treated with recombinant human activated protein C (rhAPC). High plasma IL-6 and cortisol levels at baseline significantly decreased 24 h following the infusion of rhAPC. This decrease was accompanied by a rise of circulating lymphocyte subsets. Our observation may be due to immunomodulatory properties of rhAPC.
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Affiliation(s)
- Michal Holub
- Third Department of Infectious and Tropical Diseases, First Faculty of Medicine, Charles University in Prague, Czech Republic.
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22
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Novel strategies for controlling
Streptococcus pyogenes
infection and associated diseases: from potential peptide vaccines to antibody immunotherapy. Immunol Cell Biol 2009; 87:391-9. [DOI: 10.1038/icb.2009.29] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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23
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Ulrich RG. Vaccine based on a ubiquitous cysteinyl protease and streptococcal pyrogenic exotoxin A protects against Streptococcus pyogenes sepsis and toxic shock. JOURNAL OF IMMUNE BASED THERAPIES AND VACCINES 2008; 6:8. [PMID: 18976486 PMCID: PMC2585077 DOI: 10.1186/1476-8518-6-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 10/31/2008] [Indexed: 05/25/2023]
Abstract
Background The gram-positive bacterium Streptococcus pyogenes is a common pathogen of humans that causes invasive infections, toxic-shock syndrome, rheumatic fever, necrotizing fasciitis and other diseases. Detection of antibiotic resistance in clinical isolates has renewed interest in development of new vaccine approaches for control S. pyogenes sepsis. In the study presented, a novel protein vaccine was examined. The vaccine was based on a recombinant protein fusion between streptococcal pyrogenic exotoxin B (SpeB), a cysteinyl protease expressed by all clinical isolates, and streptococcal pyrogenic exotoxin A (SpeA), a superantigen produced by a large subset of isolates. Results A novel protein was produced by mutating the catalytic site of SpeB and the receptor binding surface of SpeA in a fusion of the two polypeptides. Vaccination of HLA-DQ8 transgenic mice with the SpeA-SpeB fusion protein protected against a challenge with the wild-type SpeA that was lethal to naïve controls, and vaccinated mice were protected from an otherwise lethal S. pyogenes infection. Conclusion These results suggest that the genetically attenuated SpeA-SpeB fusion protein may be useful for controlling S. pyogenes infections. Vaccination with the SpeA-SpeB fusion protein described in this study may potentially result in protective immunity against multiple isolates of S. pyogenes due to the extensive antibody cross-reactivity previously observed among all sequence variants of SpeB and the high frequency of SpeA-producing strains.
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Affiliation(s)
- Robert G Ulrich
- Laboratory of Molecular Immunology, Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Frederick, Maryland 21702, USA.
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24
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tRNA modification by GidA/MnmE is necessary for Streptococcus pyogenes virulence: a new strategy to make live attenuated strains. Infect Immun 2008; 76:3176-86. [PMID: 18426891 DOI: 10.1128/iai.01721-07] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Studies directed at vaccine development and mucosal immunity against Streptococcus pyogenes would benefit from the availability of live attenuated strains. Our approach for production of candidate live attenuated strains was to identify mutations that did not alter growth in vitro and did not alter the overall complement of virulence factors produced but did result in reduced levels of expression of multiple secreted virulence factors. A global reduction but not elimination of expression would likely lead to attenuation while maximizing the number of antigenic targets available for stimulation of immunity. Adaptation of Tn5-based transposome mutagenesis to S. pyogenes with initial screening for reduced expression of the SpeB protease resulted in identification of mutations in gidA, which encodes an enzyme involved in tRNA modification. Reduced SpeB expression was due to delayed onset of speB transcription resulting from reduced translation efficiency of the message for RopB, a transcriptional activator. Overall, GidA(-) mutants had a nearly normal global transcription profile but expressed significantly reduced levels of multiple virulence factors due to impaired translation efficiencies. A translation defect was supported by the observation that mutants lacking MnmE, which functions in the same tRNA modification pathway as GidA, phenocopied GidA deficiency. The mutants stimulated a cytokine response in cultured macrophages identical to that in the wild type, with the exception of reduced levels of tumor necrosis factor alpha and interleukin-23. Significantly, GidA(-) mutants were highly attenuated in the murine ulcer model of soft tissue infection. These characteristics suggest that GidA pathway tRNA modification mutants are attractive candidates for further evaluation as live attenuated strains.
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25
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Wang SM, Lu IH, Lin YL, Lin YS, Wu JJ, Chuang WJ, Lin MT, Liu CC. The severity of Streptococcus pyogenes infections in children is significantly associated with plasma levels of inflammatory cytokines. Diagn Microbiol Infect Dis 2008; 61:165-9. [PMID: 18296003 DOI: 10.1016/j.diagmicrobio.2008.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 01/09/2008] [Accepted: 01/11/2008] [Indexed: 11/19/2022]
Abstract
Cytokines are intimately involved with the innate and adaptive immune response to bacterial infections. This study was designed to determine the expression of inflammatory cytokines in children by the severity of Streptococcus pyogenes (group A Streptococcus [GAS]) infections. The study population consisted of 16 invasive, 20 noninvasive, and 24 pharyngeal colonization, and 21 healthy controls. All children underwent the laboratory tests and cytokine measurement. GAS isolates were analyzed for emm gene typing. Patients with invasive GAS diseases had significantly higher interferon (IFN)-gamma, interleukin (IL)-1beta, IL-6, IL-8, IL-10, and IL-18 than those with noninvasive diseases, colonization, and healthy controls. There was no difference in tumor necrosis factor (TNF)-alpha, IL-12, and IL-2 levels among the groups. Elevated white blood cell counts and levels of C-reactive protein and C3 were detected only in patients with invasive diseases. emm1 and emm12 predominated in invasive disease and colonization. Children with invasive GAS infections exhibited significant up-regulation of plasma levels of IFN-gamma, IL-1beta, IL-6, IL-8, IL-10, and IL-18, and suppression of TNF-alpha and IL-12 during the acute phase of their illness. An exuberant cytokine response was associated with the severity of illness.
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Affiliation(s)
- Shih-Min Wang
- Department of Emergency Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan
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26
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Oettinger CW, D'souza MJ, Akhavein N, Peer GT, Taylor FB, Kinasewitz GT. Pro-inflammatory cytokine inhibition in the primate using microencapsulated antisense oligomers to NF-kappaB. J Microencapsul 2007; 24:337-48. [PMID: 17497387 DOI: 10.1080/02652040601162525] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE Antisense oligomers to NF-kappaB (ASO) were incorporated into albumin microspheres to determine if microcapsules containing ASO inhibit pro-inflammatory cytokines to a greater extent than comparable doses of ASO in solution. Phagocytosis of microcapsules and intracellular release of ASO in macrophages was evaluated. RESEARCH DESIGN Comparable doses of microencapsulated ASO and ASO in solution were evaluated in non-human primates. METHODS Blood was sampled and stimulated with Escherichia coli endotoxin ex vivo. TNF, IL-1 and IL-6 concentrations were compared for 72 hrs. The intracellular concentration of ASO was measured in macrophages in vitro to evaluate the difference in intracellular penetration of microencapsulated ASO. RESULTS Microencapsulated ASO produced significantly greater cytokine inhibition at all time points compared to ASO in solution. There were no side effects to ASO in the baboons. Intracellular ASO concentration was 10 fold greater in macrophages using microencapsulation. CONCLUSIONS Microencapsulated ASO to NF-kappaB is more effective than ASO in solution in pro-inflammatory cytokine inhibition in non-human primates.
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Affiliation(s)
- Carl W Oettinger
- College of Pharmacy and Health Sciences, Mercer University, Atlanta, GA, USA.
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27
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Påhlman LI, Olin AI, Darenberg J, Mörgelin M, Kotb M, Herwald H, Norrby-Teglund A. Soluble M1 protein of Streptococcus pyogenes triggers potent T cell activation. Cell Microbiol 2007; 10:404-14. [PMID: 17900297 DOI: 10.1111/j.1462-5822.2007.01053.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Streptococcus pyogenes of the M1 serotype is commonly associated with large outbreaks of invasive streptococcal infections and development of streptococcal toxic shock syndrome (STSS). The pathogenesis behind these infections is believed to involve bacterial superantigens that induce potent inflammatory responses, but the reason why strains of the M1 serotype are over-represented in STSS is still not understood. In the present investigation, we show that a highly purified soluble form of the M1 protein from S. pyogenes, which lacks the membrane-spanning region, is a potent inducer of T cell proliferation and release of Th1 type cytokines. M1 protein-evoked T cell proliferation was HLA class II-dependent but not MHC-restricted, did not require intracellular processing and was Vbeta-restricted. Extensive mass spectrometry studies indicated that there were no other detectable proteins in the preparation. Taken together, our data demonstrate that soluble M1 protein is a novel streptococcal superantigen, which likely contributes to the excessive T cell activation and hyperinflammatory response seen in severe invasive streptococcal infections.
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Affiliation(s)
- Lisa I Påhlman
- Department of Clinical Sciences, Section for Clinical and Experimental Infection Medicine, Lund University, Lund, Sweden
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28
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Proft T, Schrage B, Fraser JD. The Cytokine Response to Streptococcal Superantigens Varies Between Individual Toxins and Between Individuals: Implications for the Pathogenesis of Group A Streptococcal Diseases. J Interferon Cytokine Res 2007; 27:553-7. [PMID: 17651016 DOI: 10.1089/jir.2006.0173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The complete set of currently known streptococcal superantigens (SAgs) was tested for efficacy to induce in vitro cytokine responses from 5 different blood donors using the Luminex 100 system. Cytokine responses varied significantly between individual SAgs and between donors with a mixed Th1/Th2 response in 3 donors and a predominantly Th1 or Th2 response in the other 2 donors. Our results suggest that streptococcal SAgs might be involved not only in acute streptococcal diseases but also in chronic inflammation and autoimmune diseases.
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Affiliation(s)
- Thomas Proft
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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29
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Abstract
Necrotizing fasciitis (NF) is a life-threatening condition, consisting of a soft-tissue infection with rapidly progressive, widespread fascial necrosis. NF may be caused by a wide variety of microbes. Indeed, NF may be an infection of one species of bacteria or may be polymicrobial. Prompt diagnosis and treatment are essential. Surgical debridement and antibiotic therapy are the primary treatment options.
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Affiliation(s)
- G G Kihiczak
- Dermatology, New Jersey Medical School, Newark, New Jersey, USA
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30
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Abstract
Tumor necrosis factor (TNFalpha), a cardinal early mediator of the innate host inflammatory response, has been an attractive target for therapeutic intervention in human sepsis. However, pooled data from 12 completed randomized controlled trials show only a very modest impact on mortality in a highly heterogeneous population of patients. To gain insight into the preclinical in vivo biology of TNFalpha that might aid in better identifying appropriate patient populations for therapeutic intervention, we undertook a systematic review of published reports of preclinical studies assessing the consequences of neutralization of TNFalpha in models of acute infection or inflammation. We identified 143 reports incorporating 484 unique experimental comparisons in seven different animal species. The effects of neutralization of TNFalpha in these were quite variable. Neutralization of TNFalpha was beneficial in endotoxemia, or after systemic challenge with gram-negative organisms, Staphylococcus aureus, or Group B streptococci. On the other hand, neutralization was detrimental in infections caused by Streptococcus pneumoniae, Candida spp., or intracellular pathogens such as Listeria and Mycobacterium tuberculosis, and in models of pneumonia. Treatment was more efficacious when delivered before infectious challenge, and the therapeutic signal increased as the baseline mortality in the placebo group increased. Evidence of neutralization of TNFalpha bioactivity, and of attenuation of inflammation, was typically accompanied by evidence of impairment of antimicrobial defenses. Multiple specific and nonspecific therapeutic strategies were identified. We conclude that the beneficial effects of TNF in systemic inflammation occur at the cost of impaired antimicrobial defenses, and that a better understanding of the consequences of neutralization of TNFalpha in vivo could aid in better defining optimal patient populations for therapeutic intervention.
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Affiliation(s)
- José A Lorente
- Department of Critical Care Medicine, Hospital Universitario de Getafe, Madrid, Spain
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31
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Abstract
Although most bacterial infections of the skin prove to be minor in nature, a few such dermatologic entities are significant, to the point of even being fatal. Their course can be extremely rapid and can lead to dreadful complications. The mortality rate is usually up to 30% to 50% and depends upon the type of infection, underlying disease, and immune status. Patients suffering them usually need to be hospitalized, sometimes in intensive care or burn units. They should be treated systemically with appropriate antimicrobial therapy plus aggressive supportive care. The two life-threatening skin infections which are most commonly experienced are toxin-mediated staphylococcal and streptococcal disorders; one could overlap the other. Several other related entities will also be discussed.
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Affiliation(s)
- Sonya S Marina
- Department of Dermatology and Venereology, Medical University of Sofia, Bulgaria
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32
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Yang L, Thomas M, Woodhouse A, Martin D, Fraser JD, Proft T. Involvement of streptococcal mitogenic exotoxin Z in streptococcal toxic shock syndrome. J Clin Microbiol 2005; 43:3570-3. [PMID: 16000510 PMCID: PMC1169092 DOI: 10.1128/jcm.43.7.3570-3573.2005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We report a nonfatal case of streptococcal toxic shock syndrome (STSS) caused by a Streptococcus pyogenes emm118 strain encoding a novel variant of streptococcal mitogenic exotoxin Z (SMEZ-34). This variant was responsible for the major mitogenic activity in the cell culture supernatant. Patient sera showed seroconversion toward SMEZ, implying a role for this toxin in STSS.
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Affiliation(s)
- Lily Yang
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
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Mulla ZD. Treatment options in the management of necrotising fasciitis caused by Group A Streptococcus. Expert Opin Pharmacother 2005; 5:1695-700. [PMID: 15264984 DOI: 10.1517/14656566.5.8.1695] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Invasive Group A Streptococcus (GAS) disease is a serious condition that has multiple manifestations. A particularly severe form of invasive GAS disease is necrotising fasciitis (NF). The case-fatality rate of GAS NF is approximately 20%. Penicillin remains the antibiotic of choice when treating invasive GAS infections. Epidemiological studies have shown that clindamycin is effective in the treatment of deep infections that are caused by GAS. Clinicians should consider adding clindamycin to the beta-lactam antibiotic regimen when NF or myositis is present. Intravenous immunoglobulin appears to be a promising adjunctive therapy in the management of GAS NF. Consultations with surgeons and infectious disease specialists are imperative.
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Affiliation(s)
- Zuber D Mulla
- University of Texas-Houston School of Public Health, 1100 North Stanton Street, Suite 110, El Paso, TX 79902, USA.
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34
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Proft T, Sriskandan S, Yang L, Fraser JD. Superantigens and streptococcal toxic shock syndrome. Emerg Infect Dis 2004; 9:1211-8. [PMID: 14609454 PMCID: PMC3033064 DOI: 10.3201/eid0910.030042] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Lily Yang
- University of Auckland, Auckland, New Zealand
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35
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Abstract
The fulminant nature of group A streptococcal sepsis poses impressive challenges from diagnostic and therapeutic perspectives. Most patients are seen early in the course of infection by primary care providers or emergency department physicians and sent home, only to return in 12 to 24 hours with fully developed group A streptococcal sepsis. Early diagnosis is imperative, but the clinician must have a high index of suspicion. Often, the diagnosis is established only after aggressive interventional management has begun. This review emphasizes salient clinical features and provides general recommendations for critical care management.
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Affiliation(s)
- Dennis L. Stevens
- Infectious Diseases Section, Veterans Affairs Medical Center, 500 West Fort Street (Building 45), Boise, ID 83702, USA.
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36
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Mulla ZD. Nonsteroidal anti-inflammatory drugs and hypotension among patients hospitalized for invasive Group A streptococcal disease. Ann Epidemiol 2003; 13:543-4. [PMID: 12932632 DOI: 10.1016/s1047-2797(03)00071-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Falciparum malaria is a complex disease with no simple explanation, affecting organs where the parasite is rare as well as those organs where it is more common. We continue to argue that it can best be understood in terms of excessive stimulation of normally useful pathways mediated by inflammatory cytokines, the prototype being tumor necrosis factor (TNF). These pathways involve downstream mediators, such as nitric oxide (NO) that the host normally uses to control parasites, but which, when uncontrolled, have bioenergetic failure of patient tissues as their predictable end point. Falciparum malaria is no different from many other infectious diseases that are clinically confused with it. The sequestration of parasitized red blood cells, prominent in some tissues but absent in others with equal functional loss, exacerbates, but does not change, these overriding principles. Recent opportunities to stain a wide range of tissues from African pediatric cases of falciparum malaria and sepsis for the inducible NO synthase (iNOS) and migration inhibitory factor (MIF) have strengthened these arguments considerably. The recent demonstration of bioenergetic failure in tissue removed from sepsis patients being able to predict a fatal outcome fulfils a prediction of these principles, and it is plausible that this will be demonstrable in severe falciparum malaria. Understanding the disease caused by falciparum malaria at a molecular level requires an appreciation of the universality of poly(ADP-ribose) polymerase-1 (PARP-1) and Na(+)/K(+)-ATPase and the protean effects of activation by inflammation of the former that include inactivation of the latter.
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Affiliation(s)
- Ian A Clark
- School of Biochemistry and Molecular Biology, Australian National University, ACT 0200, Canberra, Australia.
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Bryant AE. Biology and pathogenesis of thrombosis and procoagulant activity in invasive infections caused by group A streptococci and Clostridium perfringens. Clin Microbiol Rev 2003; 16:451-62. [PMID: 12857777 PMCID: PMC164226 DOI: 10.1128/cmr.16.3.451-462.2003] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Group A streptococcal necrotizing fasciitis/myonecrosis and Clostridium perfringens gas gangrene are two of the most fulminant gram-positive infections in humans. Tissue destruction associated with these infections progresses rapidly to involve an entire extremity. Multiple-organ failure is common, and morbidity and mortality remain high. Systemic activation of coagulation and dysregulation of the anticoagulation pathways contribute to the pathogenesis of many diverse disease entities of infectious etiology, and it has been our hypothesis that microvascular thrombosis contributes to reduced tissue perfusion, hypoxia, and subsequent regional tissue necrosis and organ failure in these invasive gram-positive infections. This article reviews the coagulation, anticoagulation, and fibrinolytic systems from cellular players to cytokines to novel antithrombotic therapies and discusses the mechanisms contributing to occlusive microvascular thrombosis and tissue destruction in invasive group A streptococcal and C. perfringens infections. A thorough understanding of these mechanisms may suggest novel therapeutic targets for patients with these devastating infections.
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Affiliation(s)
- Amy E Bryant
- Infectious Diseases Section, Veterans Affairs Medical Center, Boise, and Department of Microbiology, University of Idaho, Moscow, Idaho.
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Bryant AE, Hayes-Schroer SM, Stevens DL. M type 1 and 3 group A streptococci stimulate tissue factor-mediated procoagulant activity in human monocytes and endothelial cells. Infect Immun 2003; 71:1903-10. [PMID: 12654807 PMCID: PMC152020 DOI: 10.1128/iai.71.4.1903-1910.2003] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Streptococcal toxic shock syndrome (StrepTSS) is an invasive infection characterized by marked coagulopathy, multiple organ failure, and rapid tissue destruction and is strongly associated with M type 1 and 3 group A streptococci (GAS). Initiation of the coagulation cascade with formation of microvascular thrombi contributes to multiple organ failure in human cases of gram-negative bacteremia; however, little is known regarding the mechanism of coagulopathy in StrepTSS. Thus, we investigated the abilities of several strains of M type 1 and 3 GAS isolated from human cases of StrepTSS to stimulate production of tissue factor (TF), the principal initiator of coagulation in vivo. Washed, killed M type 1 and 3 GAS, but not M type 6 GAS, elicited high-level TF-mediated procoagulant activity from both isolated human monocytes and cultured human umbilical vein endothelial cells. M type 1 GAS consistently elicited higher levels of TF from monocytes than did M type 3 GAS. GAS-induced TF synthesis in monocytes did not correlate with production of tumor necrosis factor alpha or interleukin-8. Conversely, M type 3 GAS were consistently more potent than M type 1 GAS in stimulating endothelial cell TF synthesis. These results demonstrate that (i) M type 1 and 3 strains of GAS are potent inducers of TF synthesis, (ii) GAS-induced TF synthesis is not simply an epiphenomenon of cytokine generation, and (iii) induction of TF in endothelial cells and monocytes may be M type specific. In total, these findings suggest that a novel interaction between GAS and host cells contributes to the observed coagulopathy in StrepTSS.
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Affiliation(s)
- A E Bryant
- Veterans Affairs Medical Center, 500 West Fort Street, Building 45, Boise, Idaho 83702, USA.
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Haller D, Serrant P, Granato D, Schiffrin EJ, Blum S. Activation of human NK cells by staphylococci and lactobacilli requires cell contact-dependent costimulation by autologous monocytes. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2002; 9:649-57. [PMID: 11986274 PMCID: PMC119993 DOI: 10.1128/cdli.9.3.649-657.2002] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
NK cells are instrumental in innate immune responses, in particular for the early production of gamma interferon (IFN-gamma) and other cytokines necessary to control certain bacterial, parasitic, and viral infections. NK cell-mediated effector functions are controlled by a fine balance between distinct receptors mediating activating and inhibitory signals; however, little is known about activating receptors on NK cells and their corresponding ligands. Several studies have shown that commensal lactobacilli isolated from the human gastrointestinal tract activate human mononuclear cells and are potent inducers of IFN-gamma and monocyte-derived interleukin 12 (IL-12). NK cell activation was shown for Lactobacillus johnsonii La1. In this study the cellular mechanisms of in vitro NK cell activation by gram-positive bacteria were analyzed. Staphylococcus aureus- and L. johnsonii La1-mediated activation of CD3(-) CD16(+) CD56(+) human peripheral blood NK cells, including expression of the activation antigen CD69 and secretion of IFN-gamma, required cell contact-dependent costimulation by autologous monocytes. S. aureus- and L. johnsonii-preactivated monocytes retained their capacity to induce NK cell activation. In contrast, cytokine-primed monocytes completely failed to induce NK cell activation unless bacteria were present. This suggests that phagocytosis of bacteria provided additional coactivation signals on accessory cells that may differ from those induced by tumor necrosis factor and IFN-gamma. Blocking of costimulatory molecules by B7.1, B7.2, and IL-12 but not CD14 monoclonal antibodies inhibited S. aureus- and L. johnsonii-induced effector function of NK cells. Our data suggest an important role for accessory cell-derived signals in the process of NK cell activation by gram-positive bacteria.
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Affiliation(s)
- D Haller
- Department of Immunology, Nestlé Research Center, 1000 Lausanne 26, Switzerland.
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Abstract
Perhaps more noteworthy than the emergence of Streptococcal toxic shock syndrome (StrepTSS) is its persistence for a period of more than 15 years in most geographical areas and an actual increase in incidence in some regions. Early diagnosis remains a problem, and aggressive surgery often cannot be avoided. The continuing rates of mortality and morbidity indicate the need for novel approaches to diagnosis and treatment.
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Barnham MRD, Weightman NC, Anderson AW, Tanna A. Streptococcal toxic shock syndrome: a description of 14 cases from North Yorkshire, UK. Clin Microbiol Infect 2002; 8:174-81. [PMID: 12010172 DOI: 10.1046/j.1469-0691.2002.00396.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyze the clinical and laboratory features of patients diagnosed with streptococcal toxic shock syndrome (TSS) in North Yorkshire from 1986 to 1999. METHODS Records of patients with features satisfying the published criteria for streptococcal TSS were reviewed from laboratory and clinical records made at the time and from the hospital case notes. Isolates of streptococci were analyzed for serotype and genes encoding for the production of streptococcal pyrogenic exotoxins. RESULTS Fourteen patients satisfied the entry criteria. In one district, where the data were complete, the annual incidence of detected streptococcal TSS rose from 1.1 to 9.5 cases per million population in the 1990s. TSS was associated with various M serotypes of group A streptococci and various exotoxin genotypes. Two cases (14% of the series) were associated with severe group G streptococcal infection. The fatality rate was 64%, and the mode of time to death was 4 days. Local tissue necrosis occurred in 71% of cases, including necrotizing fasciitis, intrathoracic and intra-abdominal forms. Non-steroidal anti-inflammatory drugs (NSAIDs) had been taken around the time of onset of disease by 92% of the patients with TSS. CONCLUSIONS There has been a dramatic increase in the number of detected cases of streptococcal TSS over the 14 years since the first case was recognized here. There was a wide range of invasive forms of infection, a high fatality rate even in fit young adults, and a rapid course from onset to death. There was a high association of TSS with aggressive streptococcal infection producing local tissue necrosis.
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Affiliation(s)
- M R D Barnham
- Department of Microbiology, Harrogate District Hospital, North Yorkshire, UK.
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Korzets A, Ori Y, Zevin D, Weinberger M, Kesslin J, Seror D, Kuperman A, Gafter U. Group A streptococcal bacteraemia and necrotizing faciitis in a renal transplant patient: a case for intravenous immunoglobulin therapy. Nephrol Dial Transplant 2002; 17:150-2. [PMID: 11773482 DOI: 10.1093/ndt/17.1.150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Asher Korzets
- Institute of Nephrology and Hypertension, Rabin Medical Center (Golda Campus), Petach Tikva, Israel.
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Affiliation(s)
- J W Park
- Division of Hematology and Oncology, Department of Medicine, University of California, San Franciso, Medical Center, San Franciscos, California 94115, USA
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Affiliation(s)
- D L Stevens
- Infectious Diseases Section, Veterans Affairs Medical Center, 500 West Fort St., Bldg 45, Boise, ID 83702, USA.
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Baxter F, McChesney J. Severe group A streptococcal infection and streptococcal toxic shock syndrome. Can J Anaesth 2000; 47:1129-40. [PMID: 11097546 DOI: 10.1007/bf03027968] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To review the literature on group A streptococcal toxic shock syndrome, (STSS). DATA SOURCE Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched. PRINCIPAL FINDINGS Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8-14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33-81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision. CONCLUSIONS Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.
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Affiliation(s)
- F Baxter
- Department of Anaesthesiology, McMaster University, St. Joseph's Hospital, Ontario, Canada.
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