True bacteria – Cocci- Gram positive cocci

Streptococci

Most of Strep. species are commensal resident of mouth, throat, so

several may act as opportunistic pathogens, also few spp. like
Strep. pyogenes and Strep. agalactiae act as primary pathogen.
Classification of Streptoccoci
Strep. are classified by 2 major methods:
1- Classification by hemolytic activity:
This depends on the type of hemolysin produced on blood agar with
5-10 % Co2 : (Figure 1).
a- Strains that produce soluble hemolysin(Streptolysin S) causing
complete clearness around the colony , called β-hemolytic
Streptococci e.g Strep. pyogenes, Strep. agalactiae.
b- Strains that produce insoluble hemolysin which causes partial lysis
called α-hemolytic Streptococci e.g Strep. pneumonia, Strep.viridans.
c- Starins that are non-hemolytic, give no change around the colonies
called γ-hemolytic streptococci e.g Strep. faecalis.
2- Serological classification (Lancefield classification).: (Figure 2)
Made by Lancefield, based on the presence of polysaccharide
antigen called
"C-substance" or "C-carbohydrate" present in the cell wall which differ
from group to another .A,B,C,D which are implicated in human
infections, and E,F,H,G and K-U which are implicated in animal
infections.
 Group A causes tonsillitis in human.
 Group B causes mastitis which is transmitted from cows to human
through contaminated milk.
 Group C causes strangles disease which transmitted to human from
horses.
 Group D which are enterococci present as normal flora in intestine
of human.
All above are β- hemolytic Strep. and the clinical important groups
are types A and B.
Antigenic Structure of Streptococci:
1- Group-Specific cell wall antigen
The carbohydrate in the cell wall of Streptococci spp.are differ
and forms the basis of serologic grouping
(Lancefield A-U).
2- M-protein
This protein is associated with virulence of group A and occurs
in organisms producing mucoid colonies, resists the phagocytosis.
3- T- substance
This antigen used to differentiate between certain types of Strep.
by agglutination with specific antisera.
4- Nucleoproteins (P-substance)
These make up most of the Strep. cell body and a little of
serologic specificity.

Groups of Streptococci
A- β-hemolytic Streptococci
1) Group A Streptococcus pyogenes
is produce human respiratory infection, such as Tonsillitis,
bronchopneumoniae, scarlet fever, erysipelas, cellulitis,
glomerulonephritis and rheumatic fever. It is bacitracin sensitive.
2) Group B Streptococcus agalactiae
are endogenous to the vaginal mucosa and been responsible for
puerperal fever, fatal neonatal meningitis and endocarditis.It is bacitracin
resistance.
3) Group C and G
Causes erysipelas, puerperal fever, throat infection, sinusitis,
bacteremia or endocarditis, occur sometimes in pharynx e.g. Strep.
equisimilis and Strep.equi.
4) Group D
Includes Enterococci, e.g. Strep. faecalis and non-Enterococci,e.g.,
Strep. bovis produces α and γ hemolysin , causes UTI or endocarditis.
5) Group E, F, H and K, U
Occur primarily in animals others can infect humans.
B- Non β-hemolytic Streptococci
These produce α-hemolysis or γ- hemolysis on blood agar, includes:
1- Strep. pneumoniae (pneumococci)
(1) bile soluble , (2) inhibited by optochin disks , (3) Quellung
reaction positive (capsule swelling test) (4) cause pneumomia and other
infection processes.
2- Strep. viridans
(1) not bile soluble , (2) not inhibited by optochin disks , (3) Quellung
reaction negative, (4) they are normal flora in upper respiratory tract in
human and may cause endocarditis.
C- Peptostreptococci
They are members of the normal flora of the gut and female genital
tract, grow aerobic or microaerophilic condition and produce variable
hemolysin.

Group A Hemolytic Streptococci (Streptoccous pyogenes):

Structural Features :
Capsule:
Hyaluronic acid resemble to that found in human connective tissue,
it is not recognized as foreign by the body, so it is non-immunogenic.
Cell wall:
a. Fimbriae: contain the major Strep. pyogenes virulence factor,
the M protein .
b. Group A specific C-carbohydrate: composed of rhamnose &
N-acetylglucoseamine.
c. Protein F (Fibronectin binding protein): which mediated
attachment to fibronectin in pharyngeal epithelium .
Extracellular products play a role in the pathogenesis (Figure3)
More than 20 extracellular products(exotoxins)are antigenic including
1- Streptokinase (Fibrinolysin)
Transforms the plasminogen of human plasma into plasmin, which
is an active proteolytic enzyme that digests fibrin and other proteins.
2- Streptodornase (DNase)
This E. depolymerizes DNA in exduates and purulent exudates,
both streptokinase and DNase help to liquefy exudates and are used for
diagnosis test of Strep. in general.
3-Hyaluronidase
It splits hyaluronic acid, component of connective tissue. it's antigenic.
4- Diphosphopyridine Nucleotidase
E is kill leukocytes.
5-Erythrogenic Toxin (Pyrogenic exotoxins)
It causes the rash in scarlet fever and
elaborated by lysogenic Strep. pyogene, also called
Dick toxin, and detected by dick test (anti toxin).
6- Hemolysin
a- Streptolysin O= labile and inactivated in O2 ,
this antigen is responsible for the produce of Ab
called (antistreptolysin O) (ASO) in human
following infection and act as a titers for diagnosis
if the serum titers of 200 units suggests recent
infection.
b- Streptolysin S= stable in O2 and causes 3
hemolytic zones around Strep. colonies on blood
agar this is not antigenic.

Clinical Findings
A- Disease due to invasion : by (1) portal of entry
of the Strep., (2) diffusion of spreading of Strep. to
different parts of the body (3) extend along
lymphatic pathways → to the blood stream.
1- Erysipelas
If the portal of entry is the skin, erysipelas results with brawny
edema.
2- Puerperal fever
By a septicemia originating in the infected wound , Strep. enters
the uterus after delivery,causes puerperal fever .
3- Sepsis/ bacteremia
Infection of traumatic or surgical wounds with Strep. results in
bacteremia/ sepsis, which can be fatal rapidly.

B- Diseases due to local infection:

1- Streptococcal sore throat
Patients have nasopharyngitis, tonsillitis and redness and edema of
the mucous membrane, with purulent exudates, and a high fever.If the
infecting Streptococci produce erythrogenic toxin scarlet fever rash will
be produced.
2- Streptococcal pyoderma
Local infection of superficial layers of skin, in children called
“impetigo”.

C- Infection of endocarditis
1- Acute endocarditis
Rapid destruction of the valves leads to fatal cardiac failure.
2- Subacute endocarditis
Due to members of the normal flora of respiratory or intestinal tract
that have accidently reached the blood.

D- Other infection
Cause UTI, suppurative lesion in the genital tract of the female.

E- Post streptococcal disease

1- Acute glomerulonephritis
occurs after 3 weeks of the infection and about 23% of children
with skin infection develops nephritis or hematuria.
2- Rheumatic fever
This is the most serious infections, because it results in damage to
heart muscles and valves, appears after 1-4 weeks of infection, causes a
complex infection all parts of the heart.
Diagnostic laboratory tests
Specimens : swab, pus, blood is obtained for culture. Serum is
obtained for Ab determination.
Microscopic examination : Gram stain: G+ spherical arranged in
chains , nonsporing , nonmotile ,noncapsulated .
Macroscopic examination: On blood agar incubated aerobically and
anaerobically to show the type of hemolysis and colonial appearance.
Biochemical tests : catalase - . sensitive for bacitracin .
Serological tests : by using ELISA, or Agglutination test.
Antistreptolysin O test ( ASO) in respiratory infections is most widely
used. Antihyaluronidase in skin infection. Antistreptokinase, anti-M
type – specific Abs and others of these.

Treatment
By penicillin G and erythromycin.
In endocarditis, a combination of penicillin G + aminoglycoside .
Penicillin prophylacticin is given to person with rheumatic fever, to
prevent recurrence of the disease (monthly for several years).
Amoxicillin is used for dental procedure.

Group B Hemolytic Streptococci (Streptococcus agalactiae)

Found as normal flora in vagina in 5-25% of woman and in
urethral mucous membranes of male carriers as well as in the G.I.T.
Their colonies on blood agar are larger and less hemolysis than Strep.
pyogenes. Resistant for bacitracin .
It can transfer from infected mothers to infants at birth and may cause:
(1) meningitis and septicemia in neonates with high mortality rate.
(2) endocarditis endometritis,
(3) septicemia or pneumonia in impaired immune systems individuals .
(4) diabetic foot infections.
Sensitive to penicillin G and ampicilline.
Streptococcus pneumonia
Antigenic Structures
A- The capsular polysaccharides (SSS)
Are used to determine by:
1- Agglutination reaction.
2- Precipitation reaction.
3- Capsular swelling reaction (Quellung reaction). Suspension of B. is
mixed with anti-polysaccharide serum on slide, the capsule swells
(Figure 4).
B- M Protein
It's characteristic for each type of Strep.
pneumonia
C- Group Specific Carbohydrate
This is common in all pneumococci , which it can
be precipitated by
(C-reactive proten ,CRP) in the serum patients.

Toxin and Virulence Factors

1- Pneumolysin O
Toxin cytolytic for cells.
2- Neuraminidase
E degrades surface structure of host tissues.
3- Capsular polysaccharide
It’s SSS which protects B. from phagocytosis .
4- C substance
The cell wall of pneumococci contain teichoic acid
(C-sub) that react with a certain antiserum protein,
C- reactive protein (CRP) and causes activation of
some nonspecific host immune response.
5- Leucocidin
Kills leukocytes W.B.C.
Pathogenesis
It’s a normal flora of nasopharynx and oropharynx in 15% of
children and 5% of adults.
They produce disease through their ability to multiply in the tissues
and it’s capsule which prevents ingestion by phagocytes.
The predispose factors to infection are: 1- Respiratory viral
4
infection 2- bronchial obstruction 3- respiratory tract injury 4- alcohol or
-3
drug intoxication .
Organism passes from person to another via respiratory secretions and
aerosols.

Clinical Findings
The pneumonia causes severe complication as meningitis in
children, endocarditis, septic arthritis.
1- Acute bacterial pneumonia
Causes of death in the aged and immunocompromised individuals
. Pneumonia is preceded by respiratory viral infection, which predisposes
to Strep. pneumonia infection of pulmonary parenchyma, by the
mechanisms of:
1) increased volume and viscosity of secretions that are more difficult to
clear
2) inhibition of the action of bronchial cilia by viral infection.
2- Otitis media
Which is the most common bacterial infection of children,
followed by Haemophils influenza and Moraxella catarrhali.
3- Bacteremia/ sepsis
Especially in splenectomized individuals.
4- Meningitis
H. influenzae was cause of bacterial meningitis ,then Strep.
pneumonia became the most common cause, which is high mortality rate
even when treated.
Laboratory identification (Table 1) :
Specimens → nasopharyngeal swab, pus, sputum or spinal fluid.
Microscopic examination : Gram stain : many neutrophiles and
many RBC. (1) G + , (2) lancet shaped (3) diplococci,
(4) nonmotile, (5) nonsporing, (6) capsulated.
Macroscopic examination : produce -hemolysin on blood agar
with 5-10% CO2. On solid media → form a small round colonies dome-
shaped at first, few hours later it undergoes some autolysis in the center
of the colony and become flat while the edges are arised.
Biochemical tests →
1- Optochin sensitivity
2- Lysis the cell by bile acids
3- Capsular swelling + (the Quellung reaction, see figure 4)
4- Inuline fermentation + (to different from Sterp. viridans )

Treatment and Prevention

Pneumococci are sensitive to sulfonamides and penicillin.
Amoxicillin, cephalosporins, erythromycin, cortimoxazole ,vancomycin
and penicillin G.Recently some drug resistance has appeared, e.g.
tetracycline, erythromycin and lincomycin.
Prevention by vaccine in infants (6 weeks – 5 years of age). This
vaccine protect invasive pneumococcal disease, in older children and
adults.

Streptococcus viridans
There growth is not inhibited by optochin disk , not soluble in bile
salt and not ferment Inuline (Differentiation between
Streptococcus pneumococcus and Streptococcus viridans
in table 1).
It’s a members of the normal flora of the upper respiratory tract, it
cause endocarditis. Some spps. like Strep. mutans produce dental caries.
Table 1: Differentiation between Streptococcus pneumococcus and
Streptococcus viridans
Strepto. pneumonia Strepto viridans
Microscopical Capsulated flame- Non capsulated oval or
morphology shaped diplococcic round arranged in
chains
Culture colonies Initially dome-shaped Dome – shaped
later flated colonies
Growth in liquid media Uniform turbidity Granular turbidity and
powdery deposits

Quelling test + _
Bile solubility + -
Inuline fermentation + -
Optochin sensitivity Sensitive Resistant
Intraperitoneal Cause fatal infection non pathogenic
inoculation in mice