Streptococcal toxic shock syndrome: a description of 14 cases from North Yorkshire, UK.

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.

Invasive M-type 3 Streptococcus pyogenes affecting a family and a residential home.

This paper describes the first recognised United Kingdom outbreak of M-type 3 streptococci for 12 years. Four epidemiologically-linked invasive infections occurred in a residential home in northern England over two weeks. The index patient was admitted from home with necrotising fasciitis of the leg. Infection was subsequently detected in her husband (fatal pneumonia) another resident (fatal pneumonia) and a member of the care staff (parapharyngeal abscess). Screening of staff and residents in the home did not reveal any further infection or carriage. There is a substantial risk of serious secondary infection amongst the contacts of a patient with invasive Streptococcus pyogenes infection. Guidance is lacking, but needed, on the advisability of chemoprophylaxis in these circumstances.

Bacteraemic Streptococcus pyogenes infection in the peri-partum period: now a rare disease and prior carriage by the patient may be important.

OBJECTIVES: To describe the features of invasive peri-partum Streptococcus pyogenes infection as it occurs in current day practice in North Yorkshire. METHODS: The case and laboratory records of all mothers and/or babies with detected S. pyogenes bacteraemia in the Harrogate and Northallerton districts of North Yorkshire (combined catchment population 260 000) were reviewed for the 20 years 1980-99. An additional bacteraemic case occurring recently in the York district was included. RESULTS: In six recorded episodes, both mother and baby were affected in three, mother only in two and baby only in one. The incidence of detected infection was one such episode per million population per year, one episode per 11 000 live births and one infected baby per 18 000 live births. Maternal features included endometritis, septicaemia, peritonitis, necrotising fasciitis and toxic shock syndrome while, in babies, infection was manifest by stillbirth or septicaemia, cyanosis, jaundice, lethargy and cellulitis. CONCLUSION: Peri-partum S. pyogenes infection is rare in North Yorkshire, with a local incidence revealed in this study of 1/million population/year, or 1:11 000 live births. Invasive neonatal infection with S. pyogenes appears to be six times less frequent in this locality than with group B streptococci. Mothers and/or their babies can be affected. Data suggests that some infection is autogenous from streptococci carried in the mother's genital tract. Although data in this setting are currently few, when a mother has suspected invasive group A streptococcal infection we recommend that the newborn child should also receive antibiotics without delay.

Observations on high levels of fusidic acid resistant Staphylococcus aureus in Harrogate, North Yorkshire, UK.

A retrospective study was carried out to investigate possible reasons for a marked increase in fusidic acid-resistant Staphylococcus aureus (FusR S. aureus) identified by our routine hospital microbiology service. Information was obtained on a sample of 64 consecutive patients from whom resistant S. aureus had been cultured. The source of isolates was found to be diffuse within the hospital and community. The site of sample was most frequently chronic cutaneous infections (68%). All the S. aureus isolates were resistant to both fusidic acid and penicillin and many were resistant to multiple antibiotics. Topical fusidic acid had been used by 40% of patients in the preceding 6 months and none had received oral fusidic acid (sodium fusidate). Most (80%) had received an oral antibiotic in the preceding 2 years. Information from the Prescriptions Pricing Authority revealed that the total number of prescriptions for fusidic acid-containing preparations for the period September 1997 to August 1998 was markedly higher in Harrogate than in five other local areas where increases in (FusR) S. aureus have not been observed.

Necrotizing proctitis caused by Streptococcus pyogenes.

We report the case of a 65-year-old patient with peritonitis, septicaemia and toxic shock syndrome in whom the primary focus of infection was acute purulent proctitis with necrosis. Streptococcus pyogenes serotype T28R28 was isolated from blood culture and peritoneal pus. The patient recovered after a prolonged period of intensive therapy and four abdominal operations including anterior resection of the rectum. We believe this to be the first clinical description of streptococcal necrotizing proctitis.

Review of 17 cases of pneumonia caused by Streptococcus pyogenes.

Streptococcus pyogenes is an uncommon cause of community-acquired pneumonia and there have been few recent specific accounts of the condition. To describe the current nature of this disease in the UK, data was gathered on patients with clinical pneumonia from whom Streptococcus pyogenes was cultured principally from blood or other relevant normally sterile sites. In the Harrogate and Northallerton districts of North Yorkshire, pneumonia accounted for nine (20%) cases and a quarter of all deaths in a complete sequence of 45 patients with Streptococcus pyogenes bacteraemia detected during the 16-year-period 1981-1996. An analysis is presented of those cases together with eight recent cases from counties York, Durham and Isle of Wight during 1995-1997. Of the total 17 cases, nine occurred in women and eight in men; the age range was 30-92 years. The organism was isolated from blood culture in 15 (88%) patients. Eight (47%) patients died, five within 1 day of hospitalisation. Fourteen (82%) cases occurred in the winter months October to March, including all the fatal cases and all eight in which a clinical 'viral' prodrome was observed. Predisposing medical or surgical conditions were present in 65% of the patients. Major complications included septicaemia, pleural reaction, shock, pulmonary cavitation, osteomyelitis and metastatic abscesses. Seven serotypes of Streptococcus pyogenes were encountered, with M-type 1 predominating (the cause in 60% of cases). All infections were community acquired; two small clusters of fatal pneumonia were seen.

Intravascular infection with Lactobacillus paracasei.

A patient is described with sub acute but life-threatening intravascular infection with Lactobacillus paracasei. Intrasplenic rupture of a mycotic aneurysm led to haematoma and early abscess formation with some bleeding into the peritoneum. The infection was cured with splenectomy and a prolonged course of ampicillin and gentamicin.

Clostridium septicum infection and hemolytic uremic syndrome.

Five cases of Clostridium septicum infection secondary to Escherichia coli O157-induced hemolytic uremic syndrome have been reported. We report on three cases (one of which is included in the above five) of dual Cl. septicum and E. coil infection; all three patients were exposed to farm animals. A common zoonotic source for Cl. septicum and E. coli O157 infections should be considered. Patients with hemolytic uremic syndrome should be treated aggressively and monitored closely for Cl. septicum superinfection.

Subtypes of Campylobacter jejuni from sporadic cases of diarrhoeal disease at different locations in England are highly diverse.

Serotyping (heat stable antigens) was performed on 398 strains of Campylobacter jejuni from faeces of human enteritis cases in England. Strains isolated over 12 months at three locations were heterogeneous with 33 HS serotypes represented. HS1 and HS4 complex were the predominant types (34% of all strains). The monthly strain frequency distributions were similar at the three locations. The late spring peak appeared to be associated with a rise in miscellaneous serotypes rather than with the emergence of any characteristic predominant serotype. PFGE DNA restriction profiling provided evidence of a high degree of genomic diversity within the common HS1 and HS4 complex serotypes, irrespective of the geographical source, yet some subtypes were common to more than one location. The study showed that C. jejuni strain subtypes from human enteric infections in England were highly diverse, and that HS serotyping must be combined with a more discriminatory subtyping method such as PFGE DNA profiling to provide an accurate basis for epidemiological surveillance.

Acute peritonsillar abscess caused by Arcanobacterium haemolyticum.

A patient is reported with a peritonsillar abscess yielding Arcanobacterium haemolyticum. This appears to be only the fifth such case described in the medical literature and the first from Europe. The organism has been reported as an occasional cause of tonsillopharyngitis with rash, resembling infection with Streptococcus pyogenes but often unresponsive to penicillin therapy. A. haemolyticum easily passes unrecognized in bacteriological cultures as a result of its slow growth, coryneform appearance in the Gram's stain and weak haemolytic activity on conventional laboratory media.