 B-hemolytic
 Growth is optimal on enriched-blood agar media but is
Streptococcus pyogenes
 Most clinical isolates of streptococci that contain the
group A antigen are S. pyogenes
 The main human pathogen associated with local or
systemic invasion and poststreptococcal immunologic
disorder
 Aka “flesh-eating” bacteria, results from life-threatening
myonecrosis
Morphology and identification
Typical Organisms
 Isolates are spherical cocci 1 to 2 µm in diameter
 Arranged in short chains in clinical specimens and longer
chains when grown in liquid media
 Gram-positive; but can lose their positivity and appears
negative; can occur after overnight incubation.
 Most group A strains produce capsules composed of
hyaluronic acid:
 capsules are most noticeable in very young cultures
 impedes phagocytosis
 hyaluronic acid capsule likely plays a greater role in
virulence
 together with M protein was believed to be an
important factor in the resurgence of rheumatic fever
(RF) in the United States
 Hairlike pili: consist partly of M protein and are covered
with lipoteichoic acid (for attachment)
 Binding of capsule to hyaluronic-acid-binding protein,
CD44, present on human epithelial cells:
 Induces disruption of intercellular junctions
 allows microorganisms to remain extracellular as
they penetrate the epithelium
Culture and Growth
 Most grows in solid media as discoid colonies;
 After 24 hours of incubation, colonies are usually 1-2mm
in diameter
inhibited if the medium contains a high concentration of
glucose.
 Lactic acid as end product
 Growth and hemolysis aided by incubation in 10% CO2
 Grows best at 37°C
 Most streptococci are facultative anaerobes
Variation
 S.pyogenes has either matte or glossy colonies
 Matte = more M protein; virulent
 Glossy = little M protein; often not virulent
Antigenic Structure
M Protein
 Major virulence factor
 A filamentous structure anchored to the cell membrane
 Molecule is a rod-like coiled structure; allows for
sequence changes while maintaining function
 Penetrates and projects from the streptococcal cell wall
 The epidemiologic classification of S. pyogenes is based
on sequence analysis of the emm gene that encodes the
M proteins.
 If present = streptococci are virulent
 If no M type-specific antibodies = can resist
phagocytosis by PMN cells by inhibition of the
activation of the alternate complement pathway
 Immunity to infection is r/t the presence of M type-
specific antibodies
 Person can have repeated infection with S. pyogenes of
different M types [as there are more than 150 types of M
protein]
 2 major structural class = I and II
 Class I: shares exposed antigens; can cause
rheumatic fever
 Does not have exposed shared antigens
 In relation to rhematic fever:
 Conserved antigenic domains on the class I M
protein cross-react with human cardiac muscle
Cell Wall
 Peptidoglycan layer
 Group-specific carbohydrate:
 10% of the dry weight of the cell (Lancefield group
A antigen)
 A dimer of N-acetylglucosamine and rhamnose.
 Used to classify group A streptococci and
distinguish them from other streptococcal groups.
Toxins and Enzymes
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Streptokinase (Fibrinolysin)
 Transforms plasminogen of human plasma into plasmin
that digests fibrin and other proteins
 Allows bacteria to escape from blood clots
 May be interfered with by nonspecific serum inhibitors
and specific antibody (antistreptokinase)
Deoxyribonucleases
 A, B, C, and D
 Degrades DNA (DNases)
 Facilitates spread of bacteria in tissue by liquefying pus
 Enzymatic activity can be measured by the decrease in
viscosity of DNA solutions
 Purulent exudates viscosity is largely due to
deoxyribonucleoprotein.
 Streptokinase + DNases = enzymatic debridement
Hyaluronidase
 Splits hyaluronic acid; aids in spreading infecting
microorganisms
 Antigenic and specific for each bacterial or tissue source
Pyrogenic Exotoxins (Erythrogenic Toxin)
 3 antigenically distinct streptococcal pyrogenic
exotoxins (Spe): A, B, and C
 Similar to the toxin produced in C. diphtheriae
 SpeA = Carries a lysogenic phase
 Spe are assoc. with streptococcal toxic shock syndrome,
necrotizing fasciitis, and scarlet fever
 either produce Spe A or have the gene that codes for
it
 SpeC = encoded by a phage; may contribute to the
syndrome
 SpeB = a potent protease, interferes with phagocytosis
 GAS assoc. with toxic shock syndrome is primarily of M
protein types 1 and 3
 Pathogenesis:
 Acts as superantigens
 Stimulates T cells by binding to the class II major
histocompatibility complex in the Vβ region of the T-
cell receptor
 activated T cells release cytokines that mediate
shock and tissue injury
Hemolysins
 Has 2 hemolysins
 Streptolysin O (SO):
 a protein (molecular weight [MW], 60,000)
 hemolytically active in the reduced state but rapidly
inactivated in the presence of O2 (oxygen-labile)
 causes hemolysis when growth occurs in cuts made
deep into the medium in blood agar plates
 combines with ASO (a human antibody) after
infection that can block hemolysis
 ASO serum titer of 160-200 units is considered
abnormally high; may be due to recent infection or
exaggerated immune response to an earlier exposure
 irreversibly inhibited by cholesterol in skin lipids, so
patients with cutaneous infections do not develop
ASO antibodies
 Streptolysin S:
 causes hemolytic zones around streptococcal
colonies growing on the surface of blood agar plates.
 Not antigenic; O2-stable
 Cell-bound hemolysin that can lyse erythrocytes,
leukocytes, and platelets
 produced in the presence of serum (the S indicates
serum stable)
Pathogenesis
Initial Host-parasite Interactions
In Rheumatic Fever
 Onset of ARF is preceded by S.pyogenes pharyngitis 1-
5wks earlier
 Not assoc. with cutaneous streptococcal infections
 Rheumatic fever occurs up to 100 times more frequently
in tropical countries
 The most important cause of heart disease in young
people in developing countries
 M types 1, 3, 5, 6, and 18 were most frequently involved.
Diagnostic Laboratory tests:
Specimens
 A throat swab, pus, CSF or other sterile body fluid, or
blood is obtained for culture.
 Serum is obtained for antibody determinations
Smears
 Smears from pus often show single cocci or pairs rather
than definite chains.
 Cocci are sometimes Gram-negative because
the organisms are no longer viable and have lost their
ability to retain the blue dye (crystal violet) and be
Gram-positive.
 If smears of pus show streptococci but cultures fail to
grow, anaerobic organisms must be suspected.
Culture
 Incubation in 10% CO2 often speeds hemolysis.
 Blood cultures will grow hemolytic group A streptococci
(eg, in sepsis) within hours or a few days
 S. pyogenes can be identified by rapid tests specific for
the presence of the group A-specific antigen and by the
PYR test.
Antigen Detection Tests
 Uses enzymatic or chemical methods to extract the
antigen from the swab, then use enzyme immunoassay
(EIA) or agglutination tests to demonstrate the presence
of the antigen.
 Completed in minutes to hours after the specimen is
obtained.
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 60–90% sensitive, depending on the prevalence of the
disease in the population, and 98–99% specific compared
with culture methods.

Serologic Tests
 Such antibodies include:
 ASO, particularly in respiratory disease
 anti-DNase B and antihyaluronidase, particularly in
skin infections
 antistreptokinase
 anti-M type-specific antibodies
 ASO test:
 To confirm ARF or acute glomerulonephritis due to
a recent streptococcal pharyngitis
 Antibodies appear 3-4 wks after initial exposure
 The anti-DNase B test should be performed if
streptococcal glomerulonephritis is suspected.

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