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Group A

Streptococcus (GAS)
Infection
Blok 26

Objective
Provide overview about diseases caused by

Group A Streptoccous (GAS)


Highlights on suppurative infection especially

Streptococcal faringits
At a glance for non-suppurative

Introduction
Group A Streptococcus (GAS) or Streptococcus pyogenes
Leading pathogenic bacteria
Infects children and adolescent
Wide spectrum of infection and disease state benign till life-

threatning
Worldwild annually
> 600 million case of strep throat
> 100 million case of GAS pyoderm

Also potential to produce delayed non suppurative sequelae

(PSAGN, ARF, PSRA)


Despite the beneficial effects of antibiotics clinicians

continue to encounter GAS disease frequently in practice .

GAS
Virulece factors :
Protein F
Protein M
Capsul
C5a peptidase
Streptolysin S
Streptolysin O
Streptococcus Pyrogenic

Exotoxin (SPE)
Hyaluronidase
Streptokinase

Virulence factors >> wide

spectrum of clincal
manifestation
Mechanism :
Suppuration

DNAase A,B,C,D

Toxin elaboration

etc

Immune-mediated inflammation

Clinical Manifestaion
Suppurative

Non-suppurative

Pharyngitis
Scarlet fever
Impetigo
Eryseplas
Celullitis
Necrotizin fascitis
STSS
Pneumonia
ets

Rheumatic Fever
GNAPS
Certain psoriasi

Pharyngitis
Upper Respiratory Infection
Largest contribution on antibiotic usage

Difficult to differentiate bacterial or viral


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

Incubation
2-4 days

Sore throat, swallowing pain, fever, malaise,

nausea, abdominal pain

Physical examination
Edematous and

hyperemic pharynx
Hypertrophy tonsil,

hyperemic, occasionally
with yellowish or
greyish exudate
Ptechiae and red

punctate in palatal area


(forscheimer spot)
Painful anterior cervical

lymphadenopathy

Diangosis
Culutre
RADT
Not common in developing country
Clinical diffculut, overlapping between GAS

and non GAS


Differential Diagnosis Bacterial, Viral,

Mycoplasma, Chlamidya

Clinical manifestation for


suggestive streptococcal and
viral pharygitis
GAS

Viral

Acute sore throat

Age 5-15 years old

Conjunctivitis

Fever

Cough

Headache

Nausea, vomiting, and


abdominal pain
Inflammation signs at tonsil
and pharynx area
Exudate at tonsil and pharynx
area

Ptechiae at palatatl area

History of contact with


streptococcal pharyngitas
patient

Scarlatiniform rash

Coryza
Diarrhea
Hoarse voice
Discrete Ulcerative

Stomatitis
Viral exanthems rash

Medication
Can be self-limited
Antibiotic :
Decrease duration of illness
Reduce contagious period
Reduce the incidence of complication
First line : Penicillin or Amoxicillin 50 mg/kg/day for 10

days
Allergic to penicillin
Cefadroxil 30 mg/kg/day 10 days
Clindamyycin 15 mg/kd/day 10 days
Azithromycin 10 mg/kg/day 5 days

Scarlet Fever
Disease in children
10% strept throat scarlet fever
Incubation : 12 hours 5 days
Fever, headache, vomiting, and abdominal

pain
After 1-2 days fine-grade sandpaper, from

neck and upper trunk whole body and


extremities, rarely spread to palms

Occasionally with pruritus, pain (-)

Obvious rash at flexor

area with pastia signs


After 3-4 days

desquamation
Flushing face with

circumoral pallor
Edematous and

hyperemic pharyx
Hypertrophy and

hyperemic tonsil with


yellowish/greyish exudate

Tongue
Tongue coated

with white
membrane and
hypertrophy
papilla (white
strawberry
tongue)
After 2 days

desquamation on
white membrane
strawberry
tongue

Diagnosis
Clinical maifestation
RADT
Swab culture

Treatment
Penicillin class or erythromycin for 10 days
Complication : abscess, sinusitis, pneumonia,

meningitis, and rheumatic fever

Impetigo
Epidermal infection
Yellowish crust above

hyperemic skin
Small papule vesicle

pustule yellowish
curust (honey-colored
crust)

Systemic sign (-)


Strain with virulence

factor M 49 corerlates
with PSAGN
Therapy topical

muporicin

Erysipelas
Skin infecton that affects

dermis and lymph vascular


system
Common etiology : GAS
Predilection area : lower

extremities and face


Acute infection :
Erythematous skin, pain,

edema with distinct


border
Red lines which cross

lesion border
Fever

Cellulitis
Progressive acute skin

inflammation on dermis
and subcutaneous
tissue
Undemarcated border,

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

lympadenopahty
Pain on infected site

Necrotizing Fasciitis
Acute and very

progressif infection
subcutaneous
tissue till fascia and
muscles
Erythematous lesion

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

Incidence followe

after minor trauma


or muscle strain
Antibiotic and

debridement

Streptococcal Toxic Shock


Syndrome
Inflammation respond fever, rash,

hypotension, and multi organ dysfunction


Related to SPEA
Happen after any site of infection
80% proceeds with skin infection at lower

limb

Diagnostic criteria (The working group of Sever Streptococcal

Infection 1993)
A. Isolation GAS form
Sterile site
Non sterile site

B. Clinical manifestaton
1. Hypotension
2. Other severe clinical disoreder (2 or more)
Renal disorder
Coagulopathy
Liver disorder
Respiratory distress
Soft tissue necrosis
Erymathous macular rash with desquamation

Definiitve case
A1, B1, and B2

Probable case
A2, B1, and B3

Treatment
Antibiotic
Admission in ICU

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