title: Scarlet fever is caused by a limited number of Streptococcus pyogenes lineages and is associated with the exotoxin genes ssa, speA and speC.
abstract: BACKGROUND
  Several outbreaks of scarlet fever caused by Streptococcus pyogenes were recently reported. Scarlet fever is historically considered a toxin-mediated disease, dependent on the production of the exotoxins SpeA and SpeC, but a strict association between scarlet fever and these exotoxins is not always detected. The aims of this study were to characterize the scarlet fever bacterial isolates recovered from patients in a Lisbon hospital and to identify any distinctive characteristics of such isolates.
  
  
  METHODS
  We characterized a collection of 303 pharyngeal S. pyogenes collected between 2002 and 2008. One-hundred and one were isolated from scarlet fever patients and 202 were associated to a diagnosis of tonsillo-pharyngitis. Isolates were characterized by T and emm typing, pulsed field gel electrophoresis profiling and superantigen gene profiling.
  
  
  RESULTS
  The diversity of the scarlet fever isolates was lower than that of the pharyngitis isolates. Specific lineages of emm87, emm4 and emm3 were overrepresented in scarlet fever isolates but only 1 pulsed field gel electrophoresis major lineage was significantly associated with scarlet fever. Multivariate analysis indicated associations of ssa, speA and speC with scarlet fever.
  
  
  CONCLUSIONS
  In nonoutbreak conditions, scarlet fever is caused by a number of distinct genetic lineages. The lower diversity of these isolates and the association with specific exotoxin genes indicates that some lineages are more prone to cause this presentation than others even in nonoutbreak conditions.
authors.affiliation: From the Instituto de Microbiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
authors.forename: Catarina
authors.initials: C
authors.lastname: Silva-Costa
authors.forename: Joao A
authors.initials: JA
authors.lastname: Carriço
authors.forename: Mario
authors.initials: M
authors.lastname: Ramirez
authors.forename: Jose
authors.initials: J
authors.lastname: Melo-Cristino
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology; D000942:Antigens, Bacterial / Q000235:genetics*; D001426:Bacterial Proteins / Q000235:genetics*; D024881:Drug Resistance, Bacterial; D016521:Electrophoresis, Gel, Pulsed-Field; D005098:Exotoxins / Q000235:genetics*; D006801:Humans; D018942:Macrolides / Q000494:pharmacology; D008565:Membrane Proteins / Q000235:genetics*; D008826:Microbial Sensitivity Tests; D012541:Scarlet Fever / Q000382:microbiology*; D013297:Streptococcus pyogenes / Q000145:classification* / Q000187:drug effects / Q000235:genetics* / Q000472:pathogenicity
chemical_list: D000900:Anti-Bacterial Agents; D000942:Antigens, Bacterial; D001426:Bacterial Proteins; D005098:Exotoxins; D018942:Macrolides; D008565:Membrane Proteins; C117980:SpeA protein, Streptococcus pyogenes; C027951:erythrogenic toxin; C117321:streptococcal superantigen SSA