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The usually controllable bug that sometimes gets nasty.

"Strep throat"--a very common diagnosis with a usually very good prognosis. With a 500 mg tablet of penicillin V twice a day, fever and sore throat are usually gone in 24 hours or so, and by the end of the ten-day treatment period the bug should be eliminated.

The offending organism is Streptococcus pyogenes, the so-called group A beta-hemolytic streptococcus, a very common bug that survives only in humans and is readily passed from person to person by respiratory droplets. Before the arrival of antibiotics, a diagnosis of strep throat or scarlet fever (strep throat with a rash, also known as scarletina) had ominous implications--and even today, Str. pyogenes can cause serious illness.

Serious complications of strep throat infection can occur if antibiotic therapy is delayed or not continued for the full ten days required to eliminate the streptococci. The most serious of these are acute glomerulonephritis and acute rheumatic fever--the former leading to chronic kidney disease and the latter to chronic heart disease.

Str. pyogenes can also cause skin infections. Impetigo, primarily an infection of children, begins around the mouth and nose with small "pimples" that quickly break down and become crusted. Secondary infection of the area with staphylococci is common. Another skin infection caused exclusively by Str. pyogenes is erysipelas, a rapidly spreading raised red rash, accompanied by fever, chills, nausea, and vomiting. Most cases occur on the lower extremities.

The most dramatic complication of strep skin infection, seen more frequently in recent years, is necrotizing fasciitis--in which Str. pyogenes becomes a "flesh-eating" bacterium. Although more frequently a complication of skin infections involving a mixture of strep and other bacteria, necrotizing fasciitis can result from a skin infection involving pure beta-hemolytic strep. When a strep skin infection gets deeper into the skin (so-called cellulitis), it can reach the tough fascial layer beneath the skin. Rather than penetrating the fascia, the infection spreads quickly along it. It thus cuts off circulation to the overlying skin, producing death of the skin and underlying soft tissue.

A more deadly complication of strep infection is toxic shock--produced when the organism gets into the bloodstream. Although more commonly due to staphylococcal infection, toxic shock is the result of a bloodborne infection that overwhelms the immune system and can rapidly lead to death.

The streptococcus organism seems to have steadily become more virulent and pervasive in the past few years. There is clear evidence that the organism can change--in either direction.

Although no one really knows why such changes take place, the streptococci seem to be changing for the worse. The sore throat that does not clear up on its own within a few days should be cultured, and if beta-strep is found, penicillin treatment should be started promptly--and carried out for a full ten days.
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Title Annotation:Streptococcus pyogenes, strep throat
Author:Brown, Edwin W.
Publication:Medical Update
Date:May 1, 1997
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