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  • Gram-positive infections are caused by Staphylococcus aureus and/or Group A Streptococcus toxin-producing bacteria.

  • Characteristic syndromes (all with skin manifestations): can be divided into 3 categories depending the predominant clinical presentation:

    • Predominantly cutaneous

      • Local: bullous impetigo

      • Generalized: Staphylococcus scalded-skin syndrome

    • Cutaneous and systemic

      • Local: recurrent toxin mediated erythema (recurrent perineal erythema)

      • Generalized: recalcitrant erythematous desquamating disorder

      • Other abortive hybrids of predominantly systemic manifestations

    • Predominately systemic

      • Generalized: toxic shock syndrome Staphylococcus (predominantly) or Streptococcus

      • Scarlet fever: Streptococcus (predominantly) or Staphylococcus

Skin infections with the Gram-positive bacteria Staphylococcus aureus and group A Streptococcus (Streptococcus pyogenes) are an important source of morbidity and mortality. These bacteria exert many of their effects via their ability to express toxins which can induce characteristic syndromes including staphylococcal scalded-skin syndrome and toxic shock syndrome. Moreover, the production of these toxins is thought to be behind the ability of infection with these bacteria to initiate and/or propagate inflammatory and neoplastic skin diseases. As is outlined in this chapter, the clinician needs to be aware that there are not only classical syndromes, but, also partial ones in which Gram-positive toxins are likely inducing effects.



Staphylococcal and streptococcal pathogenicity are caused by production of a repertoire of immunomodulatory proteins, including toxins, exoenzymes, and adhesins (reviewed in Dinges and colleagues1). Among the best characterized of these are the toxins, which are outlined in Table 152-1.

Table 152-1Toxins and Diseases Caused by Staphylococcus aureus and Group A Streptococcus

Many risk factors play a role in the ability of a toxin-forming Staphylococcus or Streptococcus to produce disease. The development of disease is related to the resistance of the host to infection and to the virulence of the organism. The host’s resistance depends, among other factors, on intact skin and mucous membranes serving as barriers to invasion and the host’s ability to mount an immune response (eg, neutralizing antibodies) against such toxins. Colonization by virulent Staphylococcus or Streptococcus toxin-producing organisms exposed to optimal, focal conditions for growth and toxin production (eg, menstruation plus tampon use or abscess) allows these bacteria to initiate and/or propagate infection.

Thus, minor defects in these barriers, such as those produced by ...

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