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spherical Gram-positive bacteria occurring in pairs or chains; cause e.g. scarlet fever and tonsillitis (同)streptococci, strep

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連鎖球菌

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/06/23 17:43:48」(JST)

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Streptococcus is a genus of coccus (spherical) Gram-positive bacteria belonging to the phylum Firmicutes^[3] and the Lactobacillales (lactic acid bacteria) order. Cellular division occurs along a single axis in these bacteria, and thus they grow in chains or pairs, hence the name—from Greek στρεπτός streptos, meaning easily bent or twisted, like a chain (twisted chain).

Contrast this with Staphylococci, which divide along multiple axes and generate grape-like clusters of cells. Most Streptococci are oxidase- and catalase-negative, and many are facultative anaerobes.

In 1984, many organisms formerly considered Streptococcus were separated out into the genera Enterococcus and Lactococcus.^[4] Currently, over 50 species are recognised in this genus.

1 Pathogenesis and classification
- 1.1 Alpha-hemolytic
  - 1.1.1 Pneumococci
  - 1.1.2 The viridans group: alpha-hemolytic
- 1.2 Beta-hemolytic
  - 1.2.1 Group A
  - 1.2.2 Group B
  - 1.2.3 Group C
  - 1.2.4 Group D (enterococci)
  - 1.2.5 Group F streptococci
  - 1.2.6 Group G streptococci
  - 1.2.7 Group H streptococci
2 Molecular taxonomy and phylogenetics
3 Genomics
4 See also
5 References
6 External links

Pathogenesis and classification

In addition to streptococcal pharyngitis (strep throat), certain Streptococcus species are responsible for many cases of pink eye,^[5] meningitis, bacterial pneumonia, endocarditis, erysipelas, and necrotizing fasciitis (the 'flesh-eating' bacterial infections). However, many streptococcal species are not pathogenic, and form part of the commensal human microbiota of the mouth, skin, intestine, and upper respiratory tract. Furthermore, streptococci are a necessary ingredient in producing Emmentaler ("Swiss") cheese.

Species of Streptococcus are classified based on their hemolytic properties.^[6] Alpha-hemolytic species cause oxidization of iron in hemoglobin molecules within red blood cells, giving it a greenish color on blood agar. Beta-hemolytic species cause complete rupture of red blood cells. On blood agar, this appears as wide areas clear of blood cells surrounding bacterial colonies. Gamma-hemolytic species cause no hemolysis.

Beta-hemolytic streptococci are further classified by Lancefield grouping, a serotype classification (that is, describing specific carbohydrates present on the bacterial cell wall).^[7] The 20 described serotypes are named Lancefield groups A to V (excluding I and J).

In the medical setting, the most important groups are the alpha-hemolytic streptococci S. pneumoniae and Streptococcus viridans group, and the beta-hemolytic streptococci of Lancefield groups A and B (also known as “group A strep” and “group B strep”).

Alpha-hemolytic

When alpha hemolysis (α-hemolysis) is present, the agar under the colony is dark and greenish. Streptococcus pneumoniae and a group of oral streptococci (Streptococcus viridans or viridans streptococci) display alpha hemolysis. This is sometimes called green hemolysis because of the color change in the agar. Other synonymous terms are incomplete hemolysis and partial hemolysis. Alpha hemolysis is caused by hydrogen peroxide produced by the bacterium, oxidizing hemoglobin to green methemoglobin.

Pneumococci

S. pneumoniae (sometimes called pneumococcus), is a leading cause of bacterial pneumonia and occasional etiology of otitis media, sinusitis, meningitis, and peritonitis. Inflammation is thought to be the major cause of how pneumococci cause disease, hence the tendency of diagnoses associated with them to involve inflammation.

The viridans group: alpha-hemolytic

The viridans streptococci are a large group of commensal bacteria, that are either α-hemolytic, producing a green coloration on blood agar plates (hence the name "viridans", from Latin vĭrĭdis, green), or nonhemolytic. They possess no Lancefield antigens.^[3]

Table: Medically relevant streptococci^[6]

Species	Host	Disease
S. pyogenes	human	pharyngitis
S. agalactiae	human, cattle	neonatal meningitis and sepsis
S. equisimilis	human, animals	endocarditis, bacteremia, pneumonia, meningitis, respiratory infections
S. bovis	human, animals	biliary or urinary tract infections, endocarditis
S. anginosus	human, animals	subcutaneous/organ abscesses, meningitis, respiratory infections
S. sanguinis	human	endocarditis, dental caries
S. suis	swine	meningitis
S. mitis	human	endocarditis
S. mutans	human	dental caries
S. pneumoniae	human	pneumonia

Beta-hemolytic

Beta hemolysis (β-hemolysis), sometimes called complete hemolysis, is a complete lysis of red cells in the media around and under the colonies: the area appears lightened (yellow) and transparent. Streptolysin, an exotoxin, is the enzyme produced by the bacteria which causes the complete lysis of red blood cells. There are two types of streptolysin: Streptolysin O (SLO) and streptolysin S (SLS). Streptolysin O is an oxygen-sensitive cytotoxin, secreted by most Group A streptococcus (GAS), and interacts with cholesterol in the membrane of eukaryotic cells (mainly red and white blood cells, macrophages, and platelets), and usually results in β-hemolysis under the surface of blood agar. Streptolysin S is an oxygen-stable cytotoxin also produced by most GAS strains which results in clearing on the surface of blood agar. SLS affects immune cells, including polymorphonuclear leukocytes and lymphocytes, and is thought to prevent the host immune system from clearing infection. Streptococcus pyogenes, or Group A beta-hemolytic Strep (GAS), displays beta hemolysis.

Some weakly beta-hemolytic species cause intense beta hemolysis when grown together with a strain of Staphylococcus. This is called the CAMP test.[1] Streptococcus agalactiae displays this property. Clostridium perfringens can be identified presumptively with this test. Listeria monocytogenes is also positive on sheep's blood agar.

Alpha-hemolytic S. viridans (right) and beta-hemolytic S. pyogenes (left) streptococci growing on blood agar

Group A

S. pyogenes, also known as group A Streptococcus (GAS), is the causative agent in a wide range of group A streptococcal infections. These infections may be noninvasive or invasive. The noninvasive infections tend to be more common and less severe. The most common of these infections include streptococcal pharyngitis (strep throat) and impetigo.^[8] Scarlet fever is also a noninvasive infection, but has not been as common in recent years.

The invasive infections caused by group A β-hemolytic streptococci tend to be more severe and less common. This occurs when the bacterium is able to infect areas where it is not usually found, such as the blood and the organs.^[9] The diseases that may be caused include streptococcal toxic shock syndrome, necrotizing fasciitis, pneumonia, and bacteremia.^[8]

Additional complications may be caused by GAS, namely acute rheumatic fever and acute glomerulonephritis. Rheumatic fever, a disease that affects the joints, kidneys, and heart valves, is a consequence of untreated strep A infection caused not by the bacterium itself. Rheumatic fever is caused by the antibodies created by the immune system to fight off the infection cross-reacting with other proteins in the body. This "cross-reaction" causes the body to essentially attack itself and leads to the damage above. Globally, GAS has been estimated to cause more than 500,000 deaths every year, making it one of the world's leading pathogens.^[8] Group A Streptococcus infection is generally diagnosed with a rapid strep test or by culture.

Group B

S. agalactiae, or group B Streptococcus, GBS, causes pneumonia and meningitis in neonates and the elderly, with occasional systemic bacteremia. They can also colonize the intestines and the female reproductive tract, increasing the risk for premature rupture of membranes during pregnancy, and transmission of the organism to the infant. The American Congress of Obstetricians and Gynecologists (formerly the American College of Obstetricians and Gynecologists), American Academy of Pediatrics, and the Centers for Disease Control recommend all pregnant women between 35 and 37 weeks gestation to be tested for GBS. Women who test positive should be given prophylactic antibiotics during labor, which will usually prevent transmission to the infant.^[10]

The United Kingdom has chosen to adopt a risk factor-based protocol, rather than the culture-based protocol followed in the US. Current guidelines state that if one or more of the following risk factors are present, then women should be treated with intrapartum antibiotics:

Preterm labour (<37 weeks)
Prolonged rupture of membranes (>18 hours)
Intrapartum fever (>38C)
Prior GBS affected infant
GBS bacteriuria during this pregnancy

This protocol results in treatment of 15–20% of pregnant women and prevention of 65–70% of cases of early onset GBS sepsis.^[11]

Group C

This group includes S. equi, which causes strangles in horses,^[12] and S. zooepidemicus—S. equi is a clonal descendent or biovar of the ancestral S. zooepidemicus—which causes infections in several species of mammals, including cattle and horses. S. dysgalactiae is also a member of group C, β-haemolytic streptococci that can cause pharyngitis and other pyogenic infections similar to group A streptococci.

Group D (enterococci)

Many former group D streptococci have been reclassified and placed in the genus Enterococcus (including E. faecalis, E. faecium, E. durans, and E. avium).^[13] For example, Streptococcus faecalis is now Enterococcus faecalis. E. faecalis is sometimes alpha hemolytic and E. faecium is sometimes beta hemolytic.^[14]

The remaining nonenterococcal group D strains include Streptococcus bovis and Streptococcus equinus.

Nonhemolytic streptococci rarely cause illness. However, weakly hemolytic group D beta-hemolytic streptococci and Listeria monocytogenes (which is actually a Gram-positive bacillus) should not be confused with nonhemolytic streptococci.

Group F streptococci

Group F streptococci were first described in 1934 by Long and Bliss amongst the "minute haemolytic streptococci".^[15] They are also known as Streptococcus anginosus (according to the Lancefield classification system) or as members of the S. milleri group (according to the European system).

Group G streptococci

These streptococci are usually, but not exclusively, beta-hemolytic. S. canis is an example of a GGS which is typically found on animals, but can cause infection in humans.

Group H streptococci

Group H streptococci cause infections in medium-sized canines. Group H streptococci rarely cause illness unless a human has direct contact with the mouth of a canine. One of the most common ways this can be spread is human-to-canine, mouth-to-mouth contact. However, the canine may lick the human's hand and infection can be spread, as well.^[16]

Molecular taxonomy and phylogenetics

Phylogenetic tree of Streptococcus species, based on data from PATRIC.^[17] 16S groups are indicated by brackets and their key members are highlighted in red.

Streptococci have been divided into six groups on the basis of their 16S rDNA sequences: S. anginosus, S.bovis, S. mitis, S. mutans, S. pyogenes and S. salivarius.^[18] The 16S groups have been confirmed by whole genome sequencing (see figure). The important pathogens S. pneumoniae and S. pyogenes belong to the S. mitis and S. pyogenes groups, respectively, while the causative agent of dental caries, Streptococcus mutans, is basal to the Streptococcus group.

Genomics

Common and species-specific genes among Streptococcus sanguinis, S. mutans, and S. pneumoniae. Modified after Xu et al. (2007) ^[19]

The genomes of hundreds of species have been sequenced.^[20] Most Streptococcus genomes are 1.8 to 2.3 Mb in size and encode 1,700 to 2,300 proteins. Some important genomes are listed in the table.^[21] The four species shown in the table (S. pyogenes, S. agalactiae, S. pneumoniae, and S. mutans) have an average pairwise protein sequence identity of about 70%.^[21]

feature	S. pyogenes	S. agalactiae	S. pneumoniae	S. mutans
base pairs	1,852,442	2,211,488	2,160,837	2,030,921
ORFs	1792	2118	2236	1963
prophages	yes	no	no	no

References

^ "Result of detail taxonomy information". TXSearch Taxonomy Retrieval. DNA Data Bank of Japan. 19 February 2010. Retrieved 30 March 2010.
^ LPSN entry for Streptococcus
^ ^a ^b Ryan KJ, Ray CG, ed. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.
^ Facklam R (October 2002). "What happened to the streptococci: overview of taxonomic and nomenclature changes". Clin. Microbiol. Rev. 15 (4): 613–30. doi:10.1128/CMR.15.4.613-630.2002. PMC 126867. PMID 12364372.
^ http://www.medicinenet.com/pink_eye/article.htm
^ ^a ^b Patterson MJ (1996). Streptococcus. In: Baron's Medical Microbiology (Baron S et al., eds.) (4th ed.). Univ of Texas Medical Branch. (via NCBI Bookshelf) ISBN 0-9631172-1-1.
^ Facklam R (2002). "What happened to the streptococci: overview of taxonomic and nomenclature changes". Clin Microbiol Rev 15 (4): 613–30. doi:10.1128/CMR.15.4.613-630.2002. PMC 126867. PMID 12364372.
^ ^a ^b ^c Cohen-Poradosu R, Kasper DL (2007). "Group A streptococcus epidemiology and vaccine implications". Clin. Infect. Dis. 45 (7): 863–5. doi:10.1086/521263. PMID 17806050.
^ "Streptococcal Infections (Invasive Group A Strep)". New York City Department of Health and Mental Hygiene. Retrieved 21 November 2012.
^ Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A (2002). "Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC". MMWR Recomm Rep 51 (RR-11): 1–22. PMID 12211284.
^ Norwitz, E.R.; Schorge, J.O. (2013). Obstetrics and Gynaecology at a Glance (4th ed.). John Wiley & Sons LTD.
^ Harrington DJ, Sutcliffe IC, Chanter N (2002). "The molecular basis of Streptococcus equi infection and disease". Microbes Infect 4 (4): 501–10. doi:10.1016/S1286-4579(02)01565-4. PMID 11932201.
^ Köhler W (June 2007). "The present state of species within the genera Streptococcus and Enterococcus". International Journal of Medical Microbiology 297 (3): 133–50. doi:10.1016/j.ijmm.2006.11.008. PMID 17400023.
^ Holt et al (1994). Bergey's Manual of Determinative Bacteriology (9th ed.). Lippincott Williams & Wilkins. ISBN 0-683-00603-7
^ Whitworth JM (November 1990). "Lancefield group F and related streptococci" (PDF). J. Med. Microbiol. 33 (3): 135–51. doi:10.1099/00222615-33-3-135. PMID 2250284.
^ "Bacterial Infection (Streptococcus) in Dogs". petmd.com. Retrieved 12 December 2014.
^ "Bacteria-Firmicutes-Bacilli-Lactobacillales-Streptococcaceae-Streptococcus". PATRIC, University of Chicago. Retrieved 12 December 2014.
^ Kawamura Y, Hou XG, Sultana F, Miura H, Ezaki T (1995). "Determination of 16S rRNA sequences of Streptococcus mitis and Streptococcus gordonii and phylogenetic relationships among members of the genus Streptococcus". Int J Syst Bacteriol 45: 406–408. doi:10.1099/00207713-45-2-406. PMID 7537076.
^ Xu, P; Alves, J. M.; Kitten, T; Brown, A; Chen, Z; Ozaki, L. S.; Manque, P; Ge, X; Serrano, M. G.; Puiu, D; Hendricks, S; Wang, Y; Chaplin, M. D.; Akan, D; Paik, S; Peterson, D. L.; MacRina, F. L.; Buck, G. A. (2007). "Genome of the opportunistic pathogen Streptococcus sanguinis". Journal of Bacteriology 189 (8): 3166–75. doi:10.1128/JB.01808-06. PMC 1855836. PMID 17277061. edit
^ Streptococcus genomes and related information at PATRIC
^ ^a ^b Ferretti JJ, Ajdic D, McShan WM (2004). "Comparative genomics of streptococcal species". The Indian journal of medical research. 119 Suppl: 1–6. PMID 15232152.

External links

Streptococcus genomes and related information at PATRIC, a Bioinformatics Resource Center funded by NIAID
"Adoption of perinatal group B streptococcal disease prevention recommendations by prenatal-care providers—Connecticut and Minnesota, 1998". MMWR Morb. Mortal. Wkly. Rep. 49 (11): 228–32. March 2000. PMID 10763673.
The Canadian Strep B Foundation
The UK Group B Strep Support charity

UpToDate Contents

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1. 連鎖球菌扁桃咽頭炎の治療および予防 treatment and prevention of streptococcal tonsillopharyngitis
2. 成人におけるA群レンサ球菌（Streptococcus pyogenes）性菌血症 group a streptococcal streptococcus pyogenes bacteremia in adults
3. 小児におけるA群レンサ球菌（化膿連鎖球菌）性菌血症 group a streptococcal streptococcus pyogenes bacteremia in children
4. 小児および思春期における急性感染性咽頭炎の診断へのアプローチ approach to diagnosis of acute infectious pharyngitis in children and adolescents
5. 妊娠していない成人におけるB群レンサ球菌感染症 group b streptococcal infections in nonpregnant adults

English Journal

Murine Model of Chronic Respiratory Inflammation.

Lugade AA, Bogner PN, Thanavala Y.Source, .
Advances in experimental medicine and biology.Adv Exp Med Biol.2012;780:125-141.
The respiratory mucosa is exposed to the external environment each time we breathe and therefore requires a robust and sophisticated immune defense system. As with other mucosal sites, the respiratory mucosal immune system must balance its response to pathogens while also regulating inflammatory imm
PMID 21842370

Tracing outbreaks of Streptococcus equi infection (strangles) in horses using sequence variation in the seM gene and pulsed-field gel electrophoresis.

Lindahl S, Soderlund R, Frosth S, Pringle J, Baverud V, Aspan A.SourceDepartment of Bacteriology, National Veterinary Institute, Uppsala, Sweden; Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden.
Veterinary microbiology.Vet Microbiol.2011 Nov 21;153(1-2):144-9. Epub 2011 Mar 30.
Strangles is a serious respiratory disease in horses caused by Streptococcus equi subspecies equi (S. equi). Transmission of the disease occurs by direct contact with an infected horse or contaminated equipment. Genetically, S. equi strains are highly homogenous and differentiation of strains has pr
PMID 21511406

Japanese Journal

Pathology : Systemic Streptococcus dysgalactiae Subspecies equisimilis Infection in a Yorkshire Pig with Severe Disseminated Suppurative Meningoencephalomyelitis

KASUYA Kazufumi,YOSHIDA Eiji,HARADA Rieko [他]
The journal of veterinary medical science 76(5), 715-718, 2014-05
NAID 40020110891

小児用肺炎球菌ワクチン導入後の健康保育園児における鼻咽頭の肺炎球菌

藤田伸二,住田裕子,齋藤綾子 [他]
日本小児科学会雑誌 = The journal of the Japan Pediatric Society 118(5), 773-778, 2014-05
NAID 40020105160

65歳からの肺炎予防 : 肺炎球菌ワクチンの重要性と有効性 (特集シニア世代の旅行医学)

服部久弥子,木田厚瑞
日本旅行医学会学会誌 11(1), 39-43, 2014-04
NAID 40020108688

Related Pictures

★リンクテーブル★

リンク元	「細菌の鑑別」「100Cases 76」「100Cases 16」「ベイヨネラ属」「連鎖球菌属」
拡張検索	「Streptococcus gordonii」「penicillin-G intermediate resistant Streptococcus pneumonae」「Streptococcus感染症」「quinolone-resistant Streptococcus pneumoniae」

「細菌の鑑別」

Streptococcus
Scientific classification
Kingdom:	Bacteria
Phylum:	Firmicutes
Class:	Bacilli
Order:	Lactobacillales
Family:	Streptococcaceae
Genus:	Streptococcus; Rosenbach, 1884
Species
	Streptococcus agalactiae; Streptococcus anginosus; Streptococcus bovis; Streptococcus canis; Streptococcus constellatus; Streptococcus dysgalactiae; Streptococcus equinus; Streptococcus iniae; Streptococcus intermedius; Streptococcus milleri; Streptococcus mitis; Streptococcus mutans; Streptococcus oralis; Streptococcus parasanguinis; Streptococcus peroris; Streptococcus pneumoniae; Streptococcus pseudopneumoniae; Streptococcus pyogenes; Streptococcus ratti; Streptococcus salivarius; Streptococcus tigurinus; Streptococcus thermophilus; Streptococcus sanguinis; Streptococcus sobrinus; Streptococcus suis; Streptococcus uberis; Streptococcus vestibularis; Streptococcus viridans; Streptococcus zooepidemicus; etc.;

　　[★]

関: 細菌

グラム陽性菌の鑑別 LAB.994

菌種	形態	抗酸性	芽胞	運動性	空気中での発育	嫌気条件下での発育	カタラーゼ	オキシダーゼ	ブドウ糖分解	OF試験
Micrococcus	C	－	－	－	＋	－	＋	－	D	O/－
Staphylococcus	C	－	－	－	＋	＋	＋	－	＋	F
Aerococcus	C	－	－	－	＋	W	W/－	－	＋	F
Streptococcus	C	－	－	＋/－	＋	＋	－	－	＋	F
Pediococcus	C.	－	－	－	＋	＋	－	－	＋	F
Gemella	C.	－	－	－	＋	＋	－	－	＋	F
嫌気性球菌*1	C	－	－	－	－	＋	－	－	＋/－	F/－
Kurthia	R	－	－	＋	＋	＋	＋	－	－	－
Corynebacterium	R	－	－	－	＋	＋	＋	－	＋/－	F/－
Listeria	R	－	－	＋	＋	＋	＋	－	＋	F
Erysipelothnx	R		－	－	＋	＋			＋	F
Lactobacillus
Arachnia*2
Rothia	R	－	－	－	＋	－	＋	●	＋	F
Propiombacterium	R	－	－	－	－	＋	＋	.	＋	F
Achnomyces	R	－	－	－	－	＋	－	●	＋	F
Bifidobacterium
Eubacterium	R	－	－	－	－	＋	－	.	＋/－	F/－
Clostridium	R	－	<＋>	D	－	＋	－	●	D	F/－
Bacillus	R	－	<＋>	D	＋	D	＋	d	D	F/O/－
Nocardia	R	W	－	－	＋	－	＋	－	＋	O
Mycobacterium	R	＋	－	－	＋	.	＋	－	＋	O/NT
1:Peptococcus, Peptostreptococus(あるいは Leuconostoc) 2:あるいはActinomyces odontolyticus D:その属の菌種によって反応が異なる。　d: 菌種によって反応が異なる。 F:発酵 O:酸化 W:弱反応・:不明 NT:テストできない <＋>:芽胞非形成筋もある C:球菌 R:桿菌

グラム陰性菌の鑑別 LAB.995

(再編集の時に－*に注意)

菌種	形態	運動性	空気中での発育	嫌気条件下での発育	カタラーゼ	オキシダーゼ	ブドウ糖(酸)	OF試験
Bacteroides	R	－	－	＋	d	－	D	F/－
Veillonella	C	－	－	＋	D	・	－	－
Neissena	C	－	＋	－	＋	＋	＋	O
Branhamella	C	－	＋	－	＋	＋	－	－
Acinetobacter	C/R	－	＋	－	＋	－	＋	O
Moraxella	R	－	＋		＋	＋	－
Brucella
Bordetella
Chromobacterium lividum	R	＋	＋	－	＋	＋	＋	O
Alcahsenes	R	＋	＋	－	＋	＋	－	－
Flavobacterium	R	－	＋	－	＋	＋	＋	O
Pseudomonas	R	＋	＋	＋	＋	＋	＋	O
Actinobacillus	R	－	＋	＋	＋	＋	＋	F
Pasteurella
Necromonas
Cardiobacterium	R	－	＋	＋	－	＋	＋	F
Chromobacterium violaceum
Beneckea	R	＋	＋	＋	＋	＋	＋	F
Vibrio
Plesiomonas
Aeromonas
腸内細菌	R	D	＋	＋	＋	－	＋	F
Haemophilus	R	－	＋	＋	D	－	D	NT
Eikenella	R	－	－*	＋	－	＋	－	－
Campylobacter	R	＋	－+1	－	D	＋	－	－
Streptobacillus+2	R	－	＋	＋	－	－	＋	F
マイコプラズマ	R	－	＋	＋	－	－	＋	F
1:Peptococcus, Peptostreptococus(あるいは Leuconostoc) 2:あるいはActinomyces odontolyticus D:その属の菌種によって反応が異なる。　d: 菌種によって反応が異なる。 F:発酵 O:酸化 W:弱反応・:不明 NT:テストできない <＋>:芽胞非形成筋もある C:球菌 R:桿菌・: 不明 *: 空気中では発育せず。空気CO2で発育。+1: 好気的または嫌気的には発育せず。5-6%O2中で発育。+2: あるいはShigella dysenteriae 1

「100Cases 76」

　　[★]

☆case76　頭痛

■glossary

傾眠 drowsiness 正常、病的の区別なく眠り込む場合に用いられる

意識不鮮明　 confusion 周囲に対する認識や理解は低下し、思考の清明さや、記憶の正確さが失われる

錯乱　 confusion　夢幻様状態より見当識障害と思考の滅裂が見られる状態(PSY.40)

MA = Master of Arts 文学修士

　The Master of Arts (BrE: MA, UsE: M.A.) is awarded in Arts, Humanities, Theology and Social Sciences (Wikipedia)

graduate student 大学院生

rousable adj. 覚醒できる、目を覚ますことができる

rouse vt. ～の目を覚まさせる、呼び起こす。喚起する、鼓舞する、奮起させる。(感情を)起こさせる、かき立てる

lateralize vt. (生理)(大脳が)(左右半球に心的機能差がある、左右差がある。(器官・機能・活動などが)大脳の(左右いずれかの)片側優位下にある。(医学)(障害などが)大脳の片半球にあると診断される

乳頭浮腫 papilledema 原因を問わず視神経乳頭が腫脹している状態

うっ血乳頭 choked disc 脳圧亢進による乳頭浮腫

■症例

24歳、男性　精神学の修士過程を専攻している大学院生

主訴：激しい頭痛

現病歴：頭部全体に痛みがある。2回嘔吐。傾眠と錯乱が認められるようになった。明るい光を嫌う()he finds bright lights uncomfortable。

既往歴：病気の既往はない。アレルギーはない。タバコ1日10本。アルコール24 unit/week(缶ビール(350ml)13.7本/週)。薬は服用してない。

家族歴：彼女と同居。3歳と4歳の子供がいる。

・診察 examination

　見た感じ紅潮しており、調子が悪そう。体温：39.2℃。項部硬直あり(he has stiffness on passice flexion of his neck)。皮疹なし。副鼻腔に圧痛なし。鼓膜所見は正常。脈拍：120/分。血圧：98/74 mmHg。心血管系、胸部、腹部に異常所見なし(normal)。意識レベル低下。命令に応じて覚醒する(JCS10？)。局所神経症状認めない。眼底所見正常

・検査 investigation

　血液検査

　　白血球：上昇。血清 Na：低下。血清尿素：上昇。血清クレアチニン：上昇。血液培養：検査中

　画像検査

　　胸部X線：異常所見なし。頭部 CT：正常

　心電図：洞性頻脈

　腰椎穿刺

　　髄液所見：混濁。白血球：増多。蛋白：増多。糖：低下(普通の人の血糖100mg/dLと考える。→　1g/L　→　1/180　mol/L　→　5.56 mmol/L。グラム染色：結果待ち

■Q

　診断、鑑別診断、管理

■A

　細菌性髄膜炎、髄膜炎・クモ膜下出血、経験的抗菌薬投与・

■解説

(第1パラグラフ)細菌性髄膜炎

・(症状)突然発症。激しい頭痛、嘔吐、錯乱、羞明、項部硬直

・低血圧、白血球増多、腎機能低下　→　ウイルス性よりむしろ細菌性の感染を示唆する。　←　重症敗血症～敗血症ショックかな？(私見)

・(髄膜炎菌の種類)

＜テーブル挿入　髄膜炎＞

・(疫学)HIM. 2621 (多分、全患者中(←私見))

　Streptococcus pneumoniae ～50%

　Neisseria meningitidis ～25%、

　group B streptococci ～15%

　Listeria monocytogenes ～10%

　Haemophilus influenzae type B <10%

・Neisseria meningitidisは全身性の脈管の皮疹(点状出血、紫斑)が特徴的(generalized vasculitic rash)

(第2パラグラフ)鑑別診断

・激しい頭痛

　・the most severe headaches are experienced in meningitis, subarachnoid hemorrhage and classic migraine.

　　・meningitis：単回の発作(single episode)。症状は時間単位で出現。

　　・subarachnoid hemorrhage：単回の発作(single episode)。突然発症(突発完成？)。硝子体出血を認めることがある。

　　・classic migraine：繰り返す(数回/年～1回/週。平均月2回。発作は4-72時間継続)

・髄膜刺激：急性に発熱をきたした多くの病態でみられる(acute febrile conditions)。特に子供。　←　そうなの？

・頚部硬直：頚部や脊椎の局所感染症でも起こる。　←　パーキンソン病などによる筋トーヌスの異常亢進も除外しよう

・他の髄膜炎：脳脊髄液所見で鑑別する

(第3パラグラフ)経験的治療

・(細菌性)髄膜炎が疑われたら、確定診断する前に適切な抗菌薬を投与(empirical treatment)。　→　数時間の経過で死亡することがある。

・ペニシリンアレルギーがなければ、ceftriaxoneかceftaximeの静脈内投与が一般的な治療法

(第4パラグラフ)腰椎穿刺

・乳頭浮腫がない、あるいは占拠性病変を示唆する片側性の神経徴候(lateralized neurological signs)がある患者では(CTの結果を待たずに)腰椎穿刺をすぐにやるべき(CASES)　←　どういう事？

・局在性の神経徴候(localized neurological sign)がある場合はまずCTを撮るべき(CASES)。　→　the dangers of coning　←　鉤ヘルニアの事？

(第5パラグラフ)細菌性髄膜炎の管理

・診断：CSF 検査(グラム染色、髄液培養(確定診断、感受性試験)

・管理

　・意識が低下しているのでそれなりの看護(must be nursed)。アヘン剤による鎮痛。生理食塩水による低ナトリウム血症の補正。低血圧を補正するために inotrope(a drug with positive inotropic effects, e.g. dobutamine, digitalis, milrinone )も必要かもしれない。(100CASES)

　・感受性のある抗菌薬の投与(大量静注、髄液移行性の高いもの)、髄液所見の正常化・CRP 陰転後、1週間抗菌薬を投与して治療を終了。対症療法として脳圧亢進には高張脳圧降下薬(マンニトールなど)を投与。(IMD.1042)

(第6パラグラフ)家族構成を考えた治療

・(意訳)誰が3-4歳の世話をしていたのか分からないけど、子供も検査すべき。髄膜炎菌か原因菌が不明だったら、リファンピシンによる予防的治療と髄膜炎球菌に対する予防接種をすべき。　←　日本ではどうなんでしょうか。

□350ml アルコール5%

350x0.05/10=1.75 unit

■莢膜を有し、髄膜炎を起こす細菌　→　莢膜を有することで血液中で補体などを介した貪食を免れ、血行性にクモ膜下腔まで到達しうる。

・Streptococcus pneumoniae

・Haemophilus influenzae type b

・Neisseria meningitidis

■敗血症

・定義

　感染症による全身性炎症反応症候群(SIRS)をセプシス(sepsis, 広義の敗血症？)とする

　感染症の病原体は、一般細菌(グラム陽性菌・陰性菌)、真菌、寄生虫、ウイルスなど

　皮膚や粘膜の傷とか、種々の臓器にある感染巣から、細菌がリンパ流から血中に入り、全身に播種されて、新たに転移性の感染巣をつくり、重篤な全身症状を引き起こす。

・全身性炎症反応症候群の診断基準

　下記項目のうち2項目以上が当てはまる

　　1. 体温>38℃ or 体温<36℃

　　2. 心拍数>90bpm

　　3. 呼吸数>20回/min or PaCO2<32mmHg

　　4. (白血球数>12,000/ul or 白血球数<4,000/ul) or ( 幼若好中球>10% )　←　ここでいう幼若好中球とは桿状好中球のことである。

・敗血症の周辺疾患概念

　1. 全身性炎症反応症候群 systemic inflammatory response syndrome SIRS

　　発熱や白血球増加などの全身の炎症の徴候によって特徴づけられる病態(SIRSの診断基準に合致する病態)

　2. 敗血症 sepsis

　　SIRSが感染の結果である場合

　3. 重症敗血症 severe sepsis

　　主要臓器障害を伴う敗血症

　4. 敗血症性ショック septic shock

　　輸液投与に不応性の低血圧を伴う重症敗血症

　5. 多臓器機能障害症候群 multiorgan dysfunction syndrome MODS

　　2つ以上の主要臓器の機能異常

　6. 多臓器不全 multiorgan failure MOF

　　2つ以上の主要臓器の不全状態

■参考文献

HIM = Harrison's Principles of Internal Medicine 17th Edition

PSY = 標準精神医学第3版

CASES = 100 Cases in Clinical Medicine Second edition

IMD = 内科診断学第2版

「100Cases 16」

　　[★]

☆case16　膝の痛み

■glossary

indigestion 消化障害、消化不良

■症例

80歳　男性

主訴：左膝の痛みと腫脹

現病歴：左膝の痛みを2日前から認めた。膝は発熱・腫脹しており、動かすと疼痛を生じる。時々胸焼けと消化不良が見られる。6ヶ月前のhealth checkで、高血圧(172/102mmHg)と血中クレアチニンが高い(正常高値)こと以外は正常といわれた。その4週間数回血圧を測定したが、高値が継続したため、2.5mg bendrofluamethizide(UK)/ベンドロフルメチアジド bendroflumethiazide(US)で治療を開始した。最近の血圧は138/84 mmHgであった。

喫煙歴：なし。

飲酒歴：一週間に平均4unit。

既往歴：股関節に中程度(mild)の変形性関節症

家族歴：特記なし

服薬歴：アセトアミノフェン(股関節の疼痛に対して)

身体所見 examination

　血圧 142/86mmHg。体温37.5℃。脈拍88/分。grade 2 hypertensive retinopathy(高血圧症性網膜症)。心血管系、呼吸器系に検査場異常なし。手にDIPにヘバーデン結節なし。

　左膝が発熱し腫脹している。関節内に液、patellar tap陽性。90℃以上膝関節を屈曲させると痛みを生じる。右の膝関節は正常に見える。

検査　 investigation

　生化学：白血球増多、ESR 上昇、尿素高値、グルコース高値

　単純X線：関節間隙やや狭小。それ以外に異常は認めない。

■problem list

　#1 左膝の痛み

　#2 胸焼け

　#3 消化不良

　#4 高血圧

　#5 クレアチニン正常高値

　#6 股関節の変形性リウマチ

　#7 高血圧性網膜症

■考え方

　・関節痛の鑑別診断を考える。

　・VINDICATEで考えてみてもよいでしょう。

　・関節痛の頻度としては　外傷＞慢性疾患(OAなど)＞膠原病＞脊椎疾患＞悪性腫瘍

■関節痛の鑑別疾患

DIF 282

V Vascular 血友病 hemophilia, 壊血病 scurvy, 無菌性骨壊死 aseptic bone necrosis (Osgood-Schlatter diseaseとか)

I Inflammatory 淋疾 gonorrhea, ライム病 lyme disease, 黄色ブドウ球菌 Staphylococcus, 連鎖球菌 Streptococcus, 結核 tuberculosis, 梅毒 syphilis, 風疹 rubella, 単純ヘルペス herpes simplex, HIV human immunodeficiency virus, サイトメガロウイルス cytomegalovirus

N Neoplastic disorders 骨原性肉腫 osteogenic sarcoma, 巨細胞腫 giant cell tumors

D Degenerative disorders degenerative joint disease or 変形性関節症 osteoarthritis

I Intoxication 痛風 gout (uric acid), 偽痛風 pseudogout (calcium pyrophosphate), ループス症候群 lupus syndrome of hydralazine (Apresoline) and procainamide, gout syndrome of diuretics

C Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.

A Autoimmune indicates (多い)関節リウマチ RA (可能性)血清病 serum sickness, 全身性エリテマトーデス lupus erythematosus, リウマチ熱 rheumatic fever, ライター症候群 Reiter syndrome, 潰瘍性大腸炎 ulcerative colitis, クローン病=限局性回腸炎 regional ileitis, 乾癬性関節炎 psoriatic arthritis (老人であり得る)リウマチ性多発筋痛症 polymyalgia rheumatica

T Trauma 外傷性滑膜炎 traumatic synovitis, tear or rupture of the collateral or cruciate ligaments, 亜脱臼 subluxation or laceration of the meniscus (semilunar cartilage), 脱臼 dislocation of the joint or patella, a 捻挫　 sprain of the joint, and fracture of the bones of the joint.

E Endcrine 先端肥大症 acromegaly, 閉経 menopause, 糖尿病 diabetes mellitus

■答え

　骨格筋系-関節炎-単関節炎-急性単関節炎

　痛風　尿酸　→　発熱、ESR↑、白血球↑

　偽痛風　ピロリン酸カルシウム

　高齢女性でチアジド系利尿薬の使用により痛風が誘発されやすい。特に腎機能低下、糖尿病の人はこのリスクが高まる。

■(BSTからの知識「)循環器領域での利尿薬

・心不全の治療において、循環血漿量を減らし、心臓の前負荷を軽減する。

・利尿薬は高尿酸血症を起こす。(けど、心不全の治療において高尿酸血症になったからといって痛風を発症している患者はみたことない)

・電解質異常を起こしやすいので、血液生化学の検査でモニタして注意する。たとえば低Kで不整脈のリスクが高まる。

・チアジド系の利尿薬は血糖を上げるし、尿酸を上げる

・長期の使用で腎機能を低下させる

■initial plan

　Dx 1. 関節液の吸引：関節液の一般検査、生化学検査、培養検査、

　　　　・白血球が増加していれば急性炎症性であることを示す。

　　　　・偏光顕微鏡で関節液を検鏡する。

　　　　　・尿酸の結晶：針状結晶。negatively birefringent

　　　　　・ピロリン酸カルシウムの結晶：positively birefringent

　Tx 1. 関節液の吸引：炎症が軽度改善

　　 2. NSAIDによる疼痛管理

　　 3. PPI：NSAID 潰瘍を予防するため

　　 4. ACE inhibitorの導入

「ベイヨネラ属」

　　[★]

ラ: Veillonella
同: Veillonella属、ベイヨネラ、ベイロネラ属、ベイロネラ
関: 細菌

[show details]

ベイヨネラ属 : 64 件
ベイロネラ属 : 15 件
ベイヨネラ : 約 206 件
ベイロネラ属 : 15 件

嫌気性
グラム陰性球菌
グルコースは利用しない
乳酸を利用して生育

StreptococcusやActinomycesと共に増殖

嫌気性連鎖球菌に含まれる

アトポビウム属細菌、ゲメラ属細菌、ベイロネラ属細菌、アシドアミノコッカス属細菌、メガスフェラ属細菌等

http:www.patentjp.com/13/L/L100983/DA10003.html

ヒトの細菌叢に含まれる細菌(2)
ヒトの口腔、消化管、膣の常在菌叢(normal flora)に含まれる。(2)
感染症において単離されることは稀。(2)
たまに髄膜炎、骨髄炎、人工関節感染、胸膜肺感染症、心内膜炎、細菌血症のような重症感染症でベイヨネラ属が単独で病原体として単離されることがある。(2)

種類

Veillonella dispar (2)
Veillonella atypica (2)
Veillonella parvula (2)
Veillonella montpellierensis (2)

参考文献

1. wikipedia en

http://en.wikipedia.org/wiki/Veillonella

2. Veillonella montpellierensis Endocarditis

http://www.cdc.gov/NCIDOD/EID/vol11no07/pdfs/04-1361.pdf

「連鎖球菌属」

　　[★]

英: Streptococcus
同: ストレプトコッカス属、Streptococcus属、ストレプトコッカス、連鎖球菌

概念

増殖に際して二連、レンサ上に配列する球形、卵円系のグラム陽性球菌の総称 (SMB.243)
連鎖球菌は属名なので、連鎖球菌属(Streptococcus属)
グラム陽性球菌
通性嫌気性菌：糖を発酵分解、乳酸を産生。
カタラーゼ非産生　←　ブドウ球菌属との判別に利用

分類

溶血の性状による分類

ヒツジ赤血球寒天培地における溶血性で分類
α溶血性:不完全溶血。緑色不透明環

β溶血性:完全溶血。透明環

化膿性連鎖球菌 Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus bovis,Streptococcus equinus

γ溶血性:非溶血性

β溶血性連鎖球菌の分類(ランスフィールドの群別, SMB.244)

細胞壁の構成成分である多糖抗原の違いにより分類

A群連鎖球菌(Streptococcus pyogenes)=化膿性連鎖球菌
B群連鎖球菌(Streptococcus agalactiae)
D群連鎖球菌(Streptococcus bovis、Streptococcus equinus

「Streptococcus gordonii」

　　[★]

日: ストレプトコッカス・ゴルドニ
関: 連鎖球菌属

「penicillin-G intermediate resistant Streptococcus pneumonae」

　　[★]

同: PISP
関: ペニシリンG、Streptococcus pneumonae

「Streptococcus感染症」

　　[★]

英: Streptococcus infection
関: 連鎖球菌属

「quinolone-resistant Streptococcus pneumoniae」

　　[★] キノロン系耐性肺炎球菌

[1] "Result of detail taxonomy information". TXSearch Taxonomy Retrieval. DNA Data Bank of Japan. 19 February 2010. Retrieved 30 March 2010.

[2] LPSN entry for Streptococcus

[Sherris-3] Ryan KJ, Ray CG, ed. (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.

[pmid12364372-4] Facklam R (October 2002). "What happened to the streptococci: overview of taxonomic and nomenclature changes". Clin. Microbiol. Rev. 15 (4): 613–30. doi:10.1128/CMR.15.4.613-630.2002. PMC 126867. PMID 12364372.

[5] ttp://www.medicinenet.com/pink_eye/article.htm

[Baron-6] Patterson MJ (1996). Streptococcus. In: Baron's Medical Microbiology (Baron S et al., eds.) (4th ed.). Univ of Texas Medical Branch. (via NCBI Bookshelf) ISBN 0-9631172-1-1.

[Facklam_2002-7] Facklam R (2002). "What happened to the streptococci: overview of taxonomic and nomenclature changes". Clin Microbiol Rev 15 (4): 613–30. doi:10.1128/CMR.15.4.613-630.2002. PMC 126867. PMID 12364372.

[Cohen-Poradosu_2007-8] Cohen-Poradosu R, Kasper DL (2007). "Group A streptococcus epidemiology and vaccine implications". Clin. Infect. Dis. 45 (7): 863–5. doi:10.1086/521263. PMID 17806050.

[9] "Streptococcal Infections (Invasive Group A Strep)". New York City Department of Health and Mental Hygiene. Retrieved 21 November 2012.

[Schrag_2002-10] Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A (2002). "Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC". MMWR Recomm Rep 51 (RR-11): 1–22. PMID 12211284.

[11] Norwitz, E.R.; Schorge, J.O. (2013). Obstetrics and Gynaecology at a Glance (4th ed.). John Wiley & Sons LTD.

[Harrington_2002-12] Harrington DJ, Sutcliffe IC, Chanter N (2002). "The molecular basis of Streptococcus equi infection and disease". Microbes Infect 4 (4): 501–10. doi:10.1016/S1286-4579(02)01565-4. PMID 11932201.

[pmid17400023-13] Köhler W (June 2007). "The present state of species within the genera Streptococcus and Enterococcus". International Journal of Medical Microbiology 297 (3): 133–50. doi:10.1016/j.ijmm.2006.11.008. PMID 17400023.

[14] Holt et al (1994). Bergey's Manual of Determinative Bacteriology (9th ed.). Lippincott Williams & Wilkins. ISBN 0-683-00603-7

[Whitworth_1990-15] Whitworth JM (November 1990). "Lancefield group F and related streptococci" (PDF). J. Med. Microbiol. 33 (3): 135–51. doi:10.1099/00222615-33-3-135. PMID 2250284.

[16] "Bacterial Infection (Streptococcus) in Dogs". petmd.com. Retrieved 12 December 2014.

[17] "Bacteria-Firmicutes-Bacilli-Lactobacillales-Streptococcaceae-Streptococcus". PATRIC, University of Chicago. Retrieved 12 December 2014.

[Kawamura1995-18] Kawamura Y, Hou XG, Sultana F, Miura H, Ezaki T (1995). "Determination of 16S rRNA sequences of Streptococcus mitis and Streptococcus gordonii and phylogenetic relationships among members of the genus Streptococcus". Int J Syst Bacteriol 45: 406–408. doi:10.1099/00207713-45-2-406. PMID 7537076.

[Xu2007-19] Xu, P; Alves, J. M.; Kitten, T; Brown, A; Chen, Z; Ozaki, L. S.; Manque, P; Ge, X; Serrano, M. G.; Puiu, D; Hendricks, S; Wang, Y; Chaplin, M. D.; Akan, D; Paik, S; Peterson, D. L.; MacRina, F. L.; Buck, G. A. (2007). "Genome of the opportunistic pathogen Streptococcus sanguinis". Journal of Bacteriology 189 (8): 3166–75. doi:10.1128/JB.01808-06. PMC 1855836. PMID 17277061. edit

[20] Streptococcus genomes and related information at PATRIC

[Ferretti2004-21] Ferretti JJ, Ajdic D, McShan WM (2004). "Comparative genomics of streptococcal species". The Indian journal of medical research. 119 Suppl: 1–6. PMID 15232152.

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案内

Streptococcus