title: Streptococcal necrotising fasciitis from diverse strains of Streptococcus pyogenes in tropical northern Australia: case series and comparison with the literature.
abstract: BACKGROUND
  Since the mid-1980's there has been a worldwide resurgence of severe disease from group A streptococcus (GAS), with clonal clusters implicated in Europe and the United States. However GAS associated sepsis and rheumatic fever have always remained at high levels in many less developed countries. In this context we aimed to study GAS necrotising fasciitis (NF) in a region where there are high background rates of GAS carriage and disease.
  
  
  METHODS
  We describe the epidemiology, clinical and laboratory features of 14 consecutive cases of GAS NF treated over a seven year period from tropical northern Australia.
  
  
  RESULTS
  Incidence rates of GAS NF in the Aboriginal population were up to five times those previously published from other countries. Clinical features were similar to those described elsewhere, with 7/14 (50%) bacteremic and 9/14 (64%) having associated streptococcal toxic shock syndrome. 11/14 (79%) had underlying chronic illnesses, including all four fatalities (29% mortality overall). Important laboratory differences from other series were that leukocytosis was absent in 9/14 (64%) but all had substantial lymphopenia. Sequence typing of the 14 NF-associated GAS isolates showed no clonality, with only one emm type 1 and two emm type 3 strains.
  
  
  CONCLUSIONS
  While NF clusters can occur from a single emergent GAS clone, this was not evident in our tropical region, where high rates of NF parallel high overall rates of GAS infection from a wide diversity of strains. The specific virulence factors of GAS strains which do cause NF and the basis of the inadequate host response in those patients who develop NF on infection with these GAS require further elucidation.
authors.affiliation: Infectious Diseases Unit, Northern Territory Clinical School, Flinders University, Royal Darwin Hospital, Darwin Northern Territory, Australia. marilynhassell@bigpond.com <marilynhassell@bigpond.com>
authors.forename: Marilyn
authors.initials: M
authors.lastname: Hassell
authors.forename: Peter
authors.initials: P
authors.lastname: Fagan
authors.forename: Phillip
authors.initials: P
authors.lastname: Carson
authors.forename: Bart J
authors.initials: BJ
authors.lastname: Currie
mesh_terms: D000328:Adult; D001315:Australia / Q000453:epidemiology; D019115:Fasciitis, Necrotizing / Q000453:epidemiology / Q000382:microbiology* / Q000503:physiopathology / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017720:Molecular Epidemiology; D013290:Streptococcal Infections / Q000453:epidemiology / Q000382:microbiology* / Q000503:physiopathology / Q000628:therapy; D013297:Streptococcus pyogenes / Q000145:classification / Q000302:isolation & purification*