Q. Write about Streptococcus. Morphology. Classification.

Diseases
caused. Laboratory diagnosis and treatment.

1.Streptococci are gram positive cocci arranged in chains or pairs.

2.They are part of normal flora of humans and animals.

3.Some of them are human pathogens.

4 The most important of them is streptococcus pyogenes.

5.This causes pyogenic infections and has a characteristic tendency

to spread.

6.Staphylococcal lesions in contrast are localized.

7.It is also responsible for non suppurative lesions, acute rheumatic

fever and glomerulonephritis which occur as sequelae to infection.

8.Alpha hemolytic streptococci produce a greenish discoloration

with partial hemolysis around the colonies.

9.The zone of lysis Is 1 -2 mm wide with indefinite margins.

10.Unlysed erythrocytes can be made out within this zone

11.They are known as viridans streptococci.

12.The alpha streptococci are normal commensals of the throat.

13. Rarely can they cause opportunistic infections.

14. Pnemococcus (streptococcus pneumoniae) is also an alpha

hemolytic streptococcus

15.Beta hemolytic streptococci produce a sharply defined, clear,

colourless zone of hemolysis, 2-4 mm wide, within which red cells
are completely hemolysed.

16. Most pathogenic streptococci belong to this group.

17. Gama hemolytic streptococci do not produce change in the

medium.

18.They include the fecal streptococci.

19.They are called the Enterococcus group.

20.Hemolytic streptococci are classified serologically by lancefield

into groups.
21. Thid was based on the nature of the carbohydrate © antigen on
the cell wall.

22.These are known as Lancefiled groups.

23. Twenty have been classified so far named A-V(without I-J).

24. Great majority of hemolytic streptococci that produce human

infections belong to group A.

25. Hemolytic streptococci of group A are known as streptococcus

pyogenes.

26. About 80 types of streptococcus pyogenes have been recognized

so far.

MORPHOLOGY

1. .The individual cocci are spherical or oval 0.5-1.0 micrometer

in diameter.
2. They are arranged in chains.
3. They are non motile or non sporing.
4. Some strains of str. Pyogenes and some group C strains have
capsules composed of hylauronic acid.
5. Polysachharide capsules are seen in members of group B and
D.It is an aerobe and facultative anaerobe.
6. It grows best at 37 deg C.
7. On blood agar after incubation for 24 hours,
8. The colonies are small (0.5-1 mm), circular, semitransparent,
low convex discs.
9. There is an area of clear hemolysis around them.
10. In liquid media such as glucose, growth appears as a
granular turbidity.
11. Biochemical reactions
12. Streptococci ferment several sugars.
13. They produce acid but no gas.
14. They are not soluble in 10% bile unlike pneumococci.
15. Streptococcus pyogenes is easily destroyed by boiling at
54 deg C for 30 minutes.
16. It dies in a few days in cultures.
17. It can survive in dust for several weeks if protected from
sunlight.
18. It is rapily inactivated by antiseptics.
 19. It is sensitive to bacitracin.
20. This is a convenient method of differentiating it from
other hemolytic streptococci.

PATHOGENICITY:

Str. Pyogenes produces infections with a tendency to spread

locally, alomg lymphatics and through the blood stream.

1.Respiratory infections:

 The primary site of invasion is the throat.

 Sore throat is the most common of streptococcal diseases.
 It may be localized as tonsillitis or may involve the pharynx
diffusely.
 Tonsillitis is more common in older children and adults than
in younger children, who commonly develop diffuse
pharyngitis.
 From the throat streptococci may spread to the surrounding
tissues leading to suppurative complications such as,
 Otitis media , mastoiditis, quinsy, ludwigs angina and
suppurative adenitis.
 It may rarely lead to meningitis.
 Streptococcal pneumonia seldom follows throat infection.

2. Skin and soft tissue infections.

 Str.pyogenes causes a variety of suppurative infections of the

skin.
 This infections infections of the wounds or burns, with a
predilection to produce
 Lymphangitis and pharyngitis.
 Infections of minor abrasions may at times lead to fatal
septicemia.
 The two typical streptococcal infections of skin are erysipelas
and impetigo
 Impetigo:
 It is mainly found in younger children.
 It is caused by a limited number of serotypes, usually the
highly numbered M types.
 Impetigo and streptoccal infections of the scabies lesions are
the main causes leading to acute glomerulonephritis in
children in the tropics.
  Steptoccocal subcutaneous infections range from cellulitis to
necrotizing fascitis
 The latter condition is more commonly caused by a mixed
aerobic and anaerobic bacterial infection.
 This is ordinarily a sporadic condition.
 Recently outbreaks in the UK and the USA have caused alarm
because of the severity and the fatality due to some strains.
 They have earned the notorious name as FLESH EATING
BACTERIA.
 There is extensive necrosis of subcutaneous and muscular
tissues.
 The adjacent fascia is associated with severe systemic illness-
 A toxic shock like syndrome with DIC and multiple system
failure.
 Str.pyogenes canc be isolated from the affected site.
 Rising titres of antistreptolysin and anti-DNAase B can be
demonstrated.
 The isolates are sensitive to penicillin invitro but may not be
invivo.
 Vancomycin is the drug of choice in life threatening infections.
 Erysipelas :
 It is rare and found mainly in older people.
 It is a diffuse infection involving superficial lymphatics.
 The affected skin is red , swollen and indurated.
 It is sharply demarcated from the surrounding area.

3. Genital infections.

 Both aerobic and anaerobic streptococci are normal

inhabitants of the female genital tract.
 Str. Pyogenes was an important cause of puerperal sepsis in
the past.

4. Other suppurative infections.

 Str. Pyogenes may cause abscess of internal organs such as

brain, lungs, liver and kidneys.
 They can also cause septicemia and pyemia.
1. Non suppurative complications.
The essential lesion in rheumatic fever is carditis.
2. This includes connective tissue degeneration of the heart
valves and
 3. Inflammatory myocardial lesions characterized by Aschoff
nodules are seen.
4. Typically , Rhematic fever persistent or repeated streptococcal
infections.
5. There is a strong antibody response
6. The lesions are believed to be a result of hypersensitivity to
some streptococcal component.
7. Rhematic fever may follow infection with any serotype of
str.pyogenes.
8. Nephritis is caused by only a few ‘nephritogenic’ types.
9. Nephritis is usually a self limiting episode.
10. It resolves without any permanent damage.

Epidemiology

1. The major source of str.pyogenes is the human upper

respiratory tract-
2. Throat, nasopharynx or nose both of patients and carriers.
3. Carrier rates of upto 20% have been observed.
4. Symptomless infection is common and helps to maintain the
organism in the community.
5. Transmission of infection is either due to direct contact or
through contaminated fingers, dust or fomites.
6. In the tropics, streptococcal infection of the skin is common.
7. Streptococcal infections of the respiratory tract are more
frequent in children between 5-8 years of age than in children
below 2 years or in adults.
8. They are more common in winter in the temperate countries.
9. Crowding is an important factor in the transmission of
infection.
10. Outbreaks may occur in closed communities such as
boarding schools.
11. Immunity is type specific.

LABORATORY DIAGNOSIS:

1. In acute infections diagnosis is established by culture.

2. In nonsuppurative complications, diagnosis is mainly based on
the demonstration of antibodies.
3. Gram stained films can be made from pus and CSF to obtain
presumptive information.
4. Presence of gram positive cocci in chains is presumptive of
streptococcal infection.
5. Smears are of no importance in infections of the throat or
genitalia because streptococci may part of the normal resident
flora.
6. The swabs are collected. They are plated immediately.
7. Or they ate sent in Pikes medium.
8. The sample is plated on Blood agar.
9. Incubated anaerobically or under 10-15 % CO2 as hemolysis
develops under these conditions.
10. Sheep blood agar is recommended for the primary
isolation because,
11. It is inhibitory for Hemophilus hemolyticus.
12. Because colonies of this organism can be confused with
hemolytic streptococci.
13. Hemolytic streptococci are grouped by the Lancefield
technique.
14. The fluorescent antibody technique has been employed
for the rapid identification of Group A streptococci.
15. Str.pyogenes is more sensitive to Bacitracin than any
other streptococci.
16. This becomes a convenient method for their
identification.
17. Rapid diagnostic tests for the identification of group A
strep are available.
18. They can give the result in 1-4 hours.
19. In Rhematic fever and glomerulonephritis, a retrospective
diagnosis can be be made
20. By demonstrating high level of antibodies to
streptococcal toxins.
21. The usual test done is antistreptolysin O.
22. ASO titers that are higher than 200 are indicative of prior
streptococcal infection.
23. AntiDNAase B estimation is also commonly employed.
24. Titres higher than 300 are taken s significant.

PROPHYLAXIS
 1. The indication for prophylaxis in streptococcal infection is only
the prevention of rheumatic fever.
2. This is by long term administration of penicillin in children who
have developed early signs of rheumatic fever.
3. This prevents streptococcal reinfection and further damage to
the heart.
4. Antibiotic prophylaxis is not useful for glomerulonephritis as
this complication follows a a single streptococcal infection.

TREATMENT:

1. All beta hemolytic streptococci are sensitive to Penicllin G and

also to eryttromycin.
2. In patients allergic to penicillin, erythromycin or cephalexin
may be used.
3. Tetracyclines and sulphonamides are recommended for those
who are resistant to
4. Erythromycin.
5. Antibiotics have no effect on established glomerulonephritis
and rheumatic fever.