Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A

N Engl J Med. 1989 Jul 6;321(1):1-7. doi: 10.1056/NEJM198907063210101.


There is concern that group A streptococci, which have caused less serious infections in developed countries in recent decades, may be acquiring greater virulence. We describe 20 patients from the Rocky Mountain region who had group A streptococcal infections from 1986 to 1988 that were remarkable for the severity of local tissue destruction and life-threatening systemic toxicity. Among the 20 patients (median age, 36), necrotizing fasciitis with or without myositis was the most common soft-tissue infection (55 percent). Nineteen patients (95 percent) had shock, 16 (80 percent) had renal impairment, and 11 (55 percent) had acute respiratory distress syndrome. The mortality rate was 30 percent. All patients but 1 had positive tissue cultures for Streptococcus pyogenes; 12 had positive blood cultures. Most of the patients had no underlying disease; 2 used intravenous drugs. Strains of group A beta-hemolytic streptococci isolated from 10 patients were not of a single M or T type; however, 8 of the 10 strains produced pyrogenic exotoxin A (scarlet fever toxin A, a classic erythrogenic toxin), which has rarely been observed in recent years. From our study of this cluster of severe streptococcal infections with a toxic shock-like syndrome, we conclude that in our region, more virulent group A streptococci have reappeared that produce the pyrogenic toxin A associated with scarlet fever.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Bacterial Proteins*
  • Exotoxins / biosynthesis*
  • Fasciitis / etiology
  • Female
  • Humans
  • Idaho
  • Male
  • Membrane Proteins*
  • Middle Aged
  • Myositis / etiology
  • Necrosis
  • Nevada
  • Pyrogens / biosynthesis*
  • Serotyping
  • Shock, Septic / epidemiology*
  • Streptococcal Infections / epidemiology*
  • Streptococcal Infections / mortality
  • Streptococcus pyogenes / isolation & purification
  • Streptococcus pyogenes / metabolism
  • Streptococcus pyogenes / pathogenicity*
  • Utah
  • Virulence


  • Bacterial Proteins
  • Exotoxins
  • Membrane Proteins
  • Pyrogens
  • SpeA protein, Streptococcus pyogenes
  • erythrogenic toxin