title: Evaluation of gastrointestinal symptoms as primary sign of severe invasive group A streptococcal infections.
abstract: OBJECTIVE
  Severe invasive infections caused by group A Streptococcus (GAS) are often associated with shock and organ failure. We describe epidemiological and disease related data from the national surveillance of invasive GAS infection in Denmark in addition to three fatal cases that occurred in Denmark in 2002 with gastrointestinal (GI) symptoms as the dominating preliminary signs.
  
  
  METHODS
  As the National Streptococcal Reference Centre The Streptococcus Unit, Statens Serum Institut (SSI) receives the vast majority of the invasive GAS isolates from patients admitted to all the hospitals in Denmark. The isolates were T-typed by slide agglutination test emm-squencing and pulsed field gel electrophoresis (PFGE) were also performed.
  
  
  RESULTS
  During January 2002 three patients died at home and GAS were found at autopsy. Cases 1 (12 yr) and 3 (25 yr) had been ill for less than two days with nausea, diarrhoea and vomiting. Case 2 (25 yr) had the same symptoms for two weeks. None of the three had any underlying diseases. The GAS isolates from cases 1 and 2 were T-type 3-13-B3264, emm89 and SpeA-, SpeC-. The third isolate was Ttype 1, emm1 and SpeA+, SpeC-. PFGE could not discriminate between the two isolates with T-type 3-13-B3264. The PFGE patterns of the three isolates were similar to those identified from GAS isolated elsewhere in Denmark at different times and from non-fatal cases. In 1999-2002, SSI received 409 isolates from patients with invasive GAS infection, and the mortality rate was 18 per cent. In 40 patients the primary symptoms were gastrointestinal, and in 30 per cent of these the outcome was fatal.
  
  
  CONCLUSIONS
  The various early clinical manifestations of severe GAS infections are still a major challenge for clinicians because of the importance of a fast and appropriate diagnosis and immediate start of treatment.
authors.affiliation: Streptococcus Unit, Department of Bacteriology, Mycology & Parasitology, Statens & Serum Institut, Denmark. kej@ssi.dk
authors.forename: K
authors.initials: K
authors.lastname: Ekelund
authors.forename: A
authors.initials: A
authors.lastname: Lemcke
authors.forename: H B
authors.initials: HB
authors.lastname: Konradsen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003718:Denmark / Q000453:epidemiology; D003967:Diarrhea / Q000150:complications; D004064:Digestive System / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009325:Nausea / Q000150:complications; D013290:Streptococcal Infections / Q000150:complications / Q000453:epidemiology / Q000382:microbiology / Q000503:physiopathology*; D013297:Streptococcus pyogenes / Q000302:isolation & purification*; D014839:Vomiting / Q000150:complications