Referat R4

8/17/2019 Referat R4

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1

Postpartum Group A StreptococcusInfection

OBSTETRY AND GYNECOLOGY DOCTOR SPECIALIST PROGRAMOBSTETRY AND GYNECOLOGY DEPARTMENT

DR. MOEWARDI CENTRAL HOSPITAL / UNS FACULTY OF MEDICINESURAKARTA 2015

REFERENCE STUDY

Prese !e" #$ % "r. D& ' Les!&r($& !)

S'*er+(s)r % "r. M. A"r(& es B&,- &s S*OG K


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INTRODUCTIONGr)'* A Streptococcus GAS (s &

-(s!)r(,& $ ( *)r!& ! ,&'se )3 *'er*er&( 3e,!() s & " se*s(s.

Des*(!e *re+e !(+e e&s'res ( , '"( 4& !(#()!(, 'se & " -)s*(!& s& (!&!()e )r!s GAS ( 3e,!() s &re re6e er4( 47)r "7("e & " re &( !-e )s! ,) )

,&'se )3 se+ere *'er*er& ( 3e,!() s

2


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T-e ( (!$ )3 GAS !) es! (s- ( 3e,!() (*)s!*&r!' *&!(e !s (s ( 8'e ,e" #$ %1. "(sr'*!e" ',)s& #&rr(ers2. & !ere" ( ' e s!&!'s )3 !-e )!-er9. & !(#()!(, &" ( (s!r&!() "'r( 4 )r

& " "e (+er$:. "e &$e" "(&4 )s(s5. e +(r) e !& e;*)s'res )3 !-e )!-er

& "e" #$ GAS

9

INTRODUCTION


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OVERVIEW

Postpartum Sepsis• P'er*er& ( 3e,!() s ,&'se )r#("(!$ ( 5610?)3 & *re4 & ! 7) e 7(!- )+er @5 000 "e&!-s/ $e&r .

• Se+er& #&,!er(& *&!-)4e s ,& ,&'se*)s!*&r!' se*s(s

• Gr)'* B Streptococcus (s )re *re+& e ! !-&GAS #'! !$*(,& $ ,&'ses ess se+ere &!er &"(se&se

• O!-er ,&'s& )r4& (s s ( , '"e s!&*-$ ),),,(Mycoplasma Chlamydia Clostridium sordellii


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OVERVIEW

Postpartum Sepsis• P)*' &r(>&!() )3 -& " -$4(e e & " r&(se !-es!& "&r"s )3 -)s*(!& , e& ( ess &!er &*)s!*&r!' ( 3e,!() s "e,re&se" "r&s!(,& $

• T-e *&s! !7) "e,&"es -&+e 7(! esse" &' e;* &( e" ( ,re&se ( se+ere *)s!*&r!'GAS ( 3e,!() s res' !( 4 ( 4re&!er ' #ers)3 &!er & "e&!-s 7)r "7("e

• A e7 'r4e ,$ !) #e!!er ' "ers!& " !-e-)s!6 (,r)#(& "e!er ( & !s )3 "(se&se !-&!

(4-! #e !&r4e!e" 3)r ( *r)+( 4 *re+e !(+e& " !-er&*e'!(, e&s'res.


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OVERVIEW

Postpartum Sepsis• GAS (s & '#( '(!)'s -' &*&!-)4e ,e ' (!(s *-&r$ 4(!(s e,r)!(>( 4s)3! !(ss'e ( 3e,!() s s,&r e! 3e+er & "( +&s(+e *'er*er& ( 3e,!() s

• P'er*er& ( 3e,!() s *rese ! r&*(" $ 7(!-(2 !) : -)'rs *)s!*&r!' & " ,& #e ) 6

s*e,(=, "e &$( 4 !re&! e !


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G.A.S

GAS (s & '#( '(!)'s -' & *&!-)4e!-&! ,&'ses & 7("e &rr&$ )3 "(se&se( , '"( 4 ,e ' (!(s *-&r$ 4(!(s

e,r)!(>( 4 s)3! !(ss'e ( 3e,!() ss,&r e! 3e+er & " ( +&s(+e *'er*er&( 3e,!() s


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G.A.S

Streptococcus pyogenes, & s) )7 &sGr)'* A Streptococcus GAS ,&'ses

( " -' & ( 3e,!() s s',- &s*-&r$ 4(!(s & " ( *e!(4) & " ser()'s( 3e,!() s s',- &s e,r)!(>( 4 3&s,((!(s& " s!re*!),),,& !);(, s-),

s$ "r) e. F'r!-er )re re*e&!e" GAS( 3e,!() s &$ !r(44er &'!)( ' e"(se&ses


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EPIDEMIOLOGY

P'er*er& se*s(s ,&'ses &! e&s! @5.000&!er & "e&!-s & '& $ )s! $

( "e+e )*( 4 ,)' !r(es & " !-e)r#("(!$ )3 *'er*er& ( 3e,!() s

& e,!s & es!( &!e" 5610? )3 *re4 & !7) e

Gr)'* A 6-e ) $!(, StreptococcusGAS S. Pyogenes) 7&s !-e & )r(,r)#(& ,&'se )3 *)s! *&r!'

( 3e,!() .


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EPIDEMIOLOGY

Se+ere GAS "(se&se ( , '"( 4 &,'!er-e' &!(, 3e+er & " ( +&s(+e( 3e,!() s (s res*) s(# e 3)r )+er50.000 "e&!-s & '& $A,,)r"( 4 !) !-e CDC &**r);( &!e $292 ,&ses )3 *)s!*&r!' ( +&s(+e GAS( 3e,!() ),,'re" ( !-e U (!e" S!&!es( 1 @ & ( ,("e ,e )3 0 0< ,&ses *er1000 (+e #(r!-s.


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EPIDEMIOLOGY

E*("e (,s )3 *'er*er& se*s(s 7ereres*) s(# e 3)r )'! !7)6!-(r"s )3

&!er & )r!& (!$ ( !-ee(4-!ee !- & " ( e!ee !- ,e !'r(esM&!er & "e&!-s -&+e #eere*)r!e" 3r) 4r)'* As!re*!),),,& ( 3e,!() ,) * (,&!e"#$ DICs


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EPIDEMIOLOGY

T-e )r!& (!$ r&!e 3)r & ( +&s(+e ,&ses(s )'! 10? !) 15? 7-ere&s )re!-& 50? )3 s!re*!),),,& !);(, s-),& " 20? )3 e,r)!(>( 4 3&s,((!(s ,&sese " ( "e&!-.I &""(!() &**r);( &!e $ 2.2? )3*ers) s 7(!- ( +&s(+e "(se&se ee! !-e,&se "e= (!() 3)r ( +&s(+e *)s!*&r!'GAS &+er&4( 4 )'! 220 ,&ses *er

$e&r ( !-e U (!e" S!&!es


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PATHOFISIOLOGY

Postpartum Sepsis Pr( &r$ s$ *!) s )3 *'er*er& ( 3e,!()( , '"e %• $& 4(&s• 3e+er• ,) 3's()• e'*-)r(&• "(>>( ess & "•

") ( & *&(

Once GAS is diagnosed, the infection isoften advanced


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PATHOFISIOLOGY

Route of Mater a! I fectio

GAS Gr)'* A S!re*!),),,'s %• ,& #e 3)' " ( !-e )r & #()!& )3 !-e3e & e re*r)"',!(+e !r&,!• (!s ,) ) (>&!() (s ,) s("ere" !) #e re &!(+e $r&re 0.09?• (!s *rese ,e & ) e (s )! s' ,(e ! !) ,&'se

"(se&se• &s$ *!) &!(,& $ ,&rr(e" ) !-e s ( )r (!-e !-r)&! #$ 5690? )3 !-e *)*' &!() & "• e&s( $ s*re&" #$ *ers) 6!)6*ers) ,) !&,! )r

&er)s) (>&!()


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PATHOFISIOLOGY

Route of Mater a! I fectio• T-e -)s! & " (,r)#(& 3&,!)rs !-&! ( 8'e ,e,) ) (>&!() *r)4ress( 4 !) ( 3e,!() %unresolved

• I! (s &**&re ! !-&! *)s!*&r!' & " *re4 & !7) e &re *re"(s*)se" !) #&,!er(& ( 3e,!() s( 4e er&

• W) e ,& #e & s)'r,e )3 ,) !& ( &!() )3!-e(r )7 re*r)"',!(+e !r&,!


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PATHOFISIOLOGY

Route of Mater a! I fectio• M)!-ers 7(!- & re,e ! -(s!)r$ )3 s)re !-r)&!s',,' # !) GAS *)s!*&r!' se*s(s ( 3e,!!-e se +es &3!er "e (+er$ % ,) !& ( &!() )3!-e *er( e' )r !-r)'4- #&,!er(& !r&+e ( !-e# ))"s!re& 3r) "(s!& )r4& s(!es

• S)'r,e )3 GAS e;*)s're ( !-e &!er &

e +(r) e ! (s !-r)'4- ( !er&,!() 7(!-,-( "re ( !-e -)'se )r &! 7)r ,-( "re 3re 'e ! GAS ,&rr(ers


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PATHOFISIOLOGY

Route of Mater a! I fectio• L& &4 ( e! & . ( +&s(+e GAS ( 3e,!() s &s &7-) e &re ) !-e r(se ( !-e 4e er& *)*' &!()% *er-&*s ,) !r(#'!( 4 !) !-e ( ,re&se (

&!er & e;*)s're ( !-e ,) ' (!$

• N)s),) (& ( 3e,!() s &re & s(4 (=,& !*)!e !(& r)'!e )3 &!er & ( 3e,!()

• H(4- ( ,("e ,e )3 -e& !-,&re6&ss),(&!e" GAS( 3e,!() s &s$ *!) &!(, -e& !-,&re67)r er,&rr(ers res' !( 4 ( s*)r&"(, *)s!*&r!' GAS

)'!#re& s ( -)s*(!& s


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PATHOFISIOLOGY

Route of Mater a! I fectio• Ces&re& se,!() % !-e s( 4 e )s! ( *)r!& !r(s 3&,!)r 3)r *)s!*&r!' &!er & ( 3e,!() (& -)s*(!& !-e ( +&s(+e &!'re )3 !-e s'r4er$

• A !(#()!(, &" ( (s!r&!() "'r( 4 )r &3!ers'r4er$ s(4 (=,& ! $ re"',es !-e r(s 3)r*)s!*&r!' ( 3e,!() #'! (s )! 100?e e,!(+e &! *re+e !( 4 ( 3e,!() s 3r)*r)4ress( 4 & " r&*(" $ ,&'s( 4 &!er & "e&!-

• I! (s e&s$ !) re4&r" ' ,) * (,&!e" *re4 & ,(es7(!- +&4( & "e (+er(es &s )76r(s 3)r se*s(s ( &-)s*(!& se!!( 4 #'! !-ere -&s #ee & ( ,re&se


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PATHOFISIOLOGY

Route of Mater a! I fectio• T-e ) 6s*e,(=, s$ *!) s &! !-e ) se! )3GAS se*s(s res' ! ( -e& !-$ 7) e #e,) ( 4,r(!(,& $ ( & " "$( 4 7(!-( & 3e7 -)'rs )r"&$s

• Re4&r" ess )3 "e (+er$ !$*e *)s!*&r!'*&!(e !s -&+e & 2063) " ( ,re&se" ( ,("e ,e )3

GAS6 ( "',e" "(se&se ,) *&re" !) ) 6*re4 & ! 7) e


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PATHOFISIOLOGY

Route of Mater a! I fectio


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PATHOFISIOLOGY

Route of Mater a! I fectioGAS virulence factors and Streptococcal ToxicShock Syndrome (STSS• GAS (s & +ers&!( e -' & *&!-)4e !-&! '!( (>es

' er)'s +(r' e ,e 3&,!)rs !) e+&"e ( ' e

re,)4 (!() )r , e&r& ,e

• GAS +(r' e ,e 3&,!)rs &(" ( e+&"( 4 *-&4),$!)s(s& " 3&,( (!&!e ( &"-ere ,e !) -)s! ,e s e&"( 4 !)

,) ) (>&!() & " ( +&s() )3 !-e -)s!• GAS -&s & 3& ( $ )3 #&,!er(& & !(4e s !-&! &re&ss),(&!e" 7(!- s!re*!),),,& !);(, s-), s$ "r) e

STSS S*eA S!re*!),),,& *$)4e (, e;)!);( AS*eC & " )!-ers !-&! #( " !) !-e MHC , &ss II


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PATHOFISIOLOGY

Route of Mater a! I fectioGAS virulence factors and Streptococcal ToxicShock Syndrome (STSS• Fami!"#s GAS of $acteria! A ti%e s res' !( 4 ( & e;,ess(+e re e&se )3( ' ) )"' &!)rs !-&! &,!(+&!e ,) * e e !,)&4' &!() & " =#r( ) $!(, ,&s,&"esres' !( 4 ( !);(, s-), & " "e&!-

• STSS -&s #ee re*)r!e" 7(!- ( +&s(+e GASs)3!6!(ss'e ( 3e,!() s 7(!- & )r!& (!$ r&!e )3&**r);( &!e $ 90?

• S!'" )3 11 E'r) e& ,)' !r(es s-)7e" &


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PATHOFISIOLOGY

Route of Mater a! I fectioGAS virulence factors and Streptococcal ToxicShock Syndrome (STSS

• S*eA (s !-e s'*er& !(4e )s! ,) ) $ GAS ( 3e,!() s !-&! res' ! ( STSS ( !-e US& "• Ge ) e se 'e ,e ,) *&r(s) s )3 GAS*&!(e ! (s) &!es re+e& e7 +&r(& !s )3 speA ( ,re&se" se+er(!$ )3 !-ese , ( (,& s!r&( s (*)s!*&r!' ( 3e,!() s


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PATHOFISIOLOGY

Route of Mater a! I fectioImmune recognition of GAS• GAS (s re,)4 (>e" #$ !-e ( &!e ( ' eres*) se.• GAS (s re,)4 (>e" #$ & ' ("e !(=e" M$D 6"e*e "e ! re,e*!)r ( "e*e "e ! )3 TLR2

TLR: & " TLR &,!(+&!()• in vitro s!'"(es GAS &,!(+&!() )3 *9

MAPK NF6 B TNF IL6< & " !$*e 1 IFN*r)"',!() :2 ( "(,&!( 4 -)s! ( ' e&,!(+&!() .• GAS & e;!r&,e ' &r *&!-)4e #'! re,e !

rese&r,- GAS s'r+(+& 7(!-( ' !(* e -)s!


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PATHOFISIOLOGY

Route of Mater a! I fectioImmune recognition of GAS• B()*s(es 3r) *&!(e !s 7(!- se+ere GAS !(ss'e( 3e,!() s ,) !&( e" +( e GAS 7(!-(

&,r)*-&4es ,) =r ( 4 !-e(r ( !r&,e ' &rs'r+(+& ( (!$.

• GAS s'r+(+& ( e*(!-e (& ,e s &$ ,) !r(#'!e

!) se+ere GAS *)s!*&r!' ( 3e,!() s #$*r)+("( 4 & ),&!() 3)r s$s!e (, ( +&s() )r!-e ( (!(&!() )3 STSS


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PATHOFISIOLOGY

Postpartum P&"sio!o%" a ' Imu o!o%" • T-e 4r&+(" 3e & e re*r)"',!(+e !r&,! FRTe +(r) e ! (s ' ( 'e ( (!s ( ' ) )4$• T-e &!er & ( ' e s$s!e 's! #e !) er& !!) !-e ( "(4e )'s #&,!er(& ( !-e re*r)"',!(+e!r&,! !) *&!er & & !(4e s ( s*er & " !) !-e( ' ) )4(,& $6"(s!( ,! 3e!'s• Pre4 & ,$ !& es * &,e ( & *-$s() )4(,& $ & "( ' ) )4(,& $ "(s!( ,! )r4& 7(!- (!s )7

',)s& #&rr(er '!er's & " "e,("'& & "&,,) )"&!es & & )4e e(, 3e!'s• H)r ) & *r)"',!s FRT & !er !-e ( ' eres*) se & " !-e 3e!'s ,-& e 4es !-e

&!er & ( ' e s s!e &s (!s s(>e & "


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PATHOFISIOLOGY

Postpartum P&"sio!o%" a ' Imu o!o%" • Pr)s!&4 & "( PG E2 IL6: & " IL610 &re( "',e" #$ *re4 & ,$ & " s'**ress !-e

&!er & T-1 ( ' e res*) se re+(e7e" (109 & " !-e s$s!e (, ")7 6re4' &!() )3 !-e

T-1 res*) se res' !s ( ( ' e & !er&!() s!-&! *r) )!e &!er & s's,e*!(#( (!$ !)( 3e,!()•

Pre4 & ,$ -&s )3!e #ee re3erre" !) &s & T-26!$*e ( ' e s!&!e #'! *re4 & ,$ (s &)"' &!e" ( ' e s!&!e !-&! (s )! s( * $

& !(6( 8& &!)r$ #'! (s ,) !( '& $ ,-& 4( 4

"'r( 4 3e!& "e+e )* e !


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PATHOFISIOLOGY

Prosta%!a 'i E(• T-e (*(" e"(&!)r PGE2 "eser+es s*e,(&

e !() #e,&'se (! -&s e er4e" &s &( *)r!& ! )"' &!)r )3 -)s! ( ' (!$es*e,(& $ "'r( 4 *re4 & ,$ & " !-e*)s!*&r!' *er()"• PGE2 (s & &r&,-(") (, &,("6"er(+e" e"(&!)r!-&! )"' &!es ,e #e-&+()r +(& !-e (4&!() )3

3)'r "(s!( ,! G *r)!e( ,)'* e" re,e*!)rs ,& e"E *r)s!& )(" EP re,e*!)rs 7-(,- &re' #ere" EP16:

• T-r)'4-)'! 4es!&!() PGE2 "& *e s

&!er & ( ' e res*) ses &4&( s! 3e!&


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PATHOFISIOLOGY

Prosta%!a 'i E(• E e+&!() ( PGE2 e+e s -&s *re+()'s $ #ees-)7 !) * &$ & r) e ( -)s! s's,e*!(#( (!$ !)( 3e,!() s ( & $ *&!(e ! *)*' &!() s( , '"( 4 *re4 & ! 7) e• T-e ,&*&,(!$ 3)r PGE2 !) re4' &!e -)s!6

(,r)#(& ( !er&,!() s (s ( ,re&s( 4 $ e+("e ! (!-e ,) !e;! )3 s!re*!),),,& ( 3e,!() s•

Pr)s!&4 & "( e ")*er);("e s$ !-&se 2 CO 62 (s !-e e >$ e !-&! ,) +er!s &r&,-(") (,&,(" ( !) *r)s!&4 & "( e ")*er);("e H2

PGH2 #e3)re PGH2 (s ,) +er!e" ( !) )!-er

*r)s!&4 & "( s.


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PATHOFISIOLOGY

FRT Mucus)pH) I 'i%e ous Micro*iota• &4( & ,) ) (>&!() #$ GAS &**e&rs !) #e &( *)r!& ! *re,e"( 4 e+e ! ( s) e ,&ses )3*'er*er& se*s(s 3) )7( 4 +&4( & "e (+er$• T-e ( &!e ( ' e e,-& (s s !-&! *re+e !GAS 3r) &s,e "( 4 !-r)'4- !-e ,er+(,& ,& &( !) !-e *)s!*&r!' '!er's re &(( ,) * e!e $ ' "ers!))"•

M','s 7(!-( !-e FRT *r)!e,!s e*(!-e (& ,e s3r) #&,!er(& ( 3e,!() s !-r)'4- se+er&e,-& (s s.

• M','s ,& *-$s(,& $ !r&* *)!e !(&

*&!-)4e s & " ( -(#(! *&!-)4e s'r+(+& "'e


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PATHOFISIOLOGY

FRT Mucus)pH) I 'i%e ous Micro*iota• T-e ( "(4e )'s #&,!er(& ( !-e re*r)"',!(+e!r&,! & s) *r)+("e *&!-)4e res(s!& ,e !-r)'4-se+er& e& s ( , '"( 4 ,) *e!(!(+ee;, 's() )3 *&!-)4e (, (,r)#es & ",) !r(#'!( 4 !) !-e &,("(, +&4( & e +(r) e !!-r)'4- &,!(, &,(" *r)"',!() .

•

Lactobacillus spp. &re !-e )s! ,) )#&,!er(& *rese ! &,r)ss & e!- (, 4r)'*s & "*r)"',e &,!(, &,(" ( !-e FRT


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PATHOFISIOLOGY

FRT Mucus)pH) I 'i%e ous Micro*iota• Me #r& es ,) e,!e" 3r) -e& !-$ 7) e3) )7( 4 &! !er ,es&re& se,!() s"e ) s!r&!e #&,!er(& DNA ( '* !) @0? )3s& * es ( "(,&!( 4 & "$ & (, -)s! ,) !r) )3( "(+("'& #&,!er(& "(+ers(!$ ( -e& !-$*re4 & ,(es


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+LI,I+AL FEAT-RE

GAS *e +(, ( 3e,!() s &$ -&+e &*&',(!$ )3 s$ *!) s )r s(4 s re &!e" !)!-e 4e (!& !r&,! 7(!- ) 6s*e,(=,s$ *!) s )r 4&s!r)( !es!( &

& (3es!&!() s *re") ( &!( 4


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+LI,I+AL FEAT-RE


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+LI,I+AL FEAT-RE

T-e s(4 s & " s$ *!) s )3 ( 3e,!() #$GAS ( , '"( 4 *$re;(&/3e+er s7e ( 4er$!-e & "r&( &4e & " *&( &! !-e s(!e)3 !-e 7)' ".

T-(s (s )3 s*e,(& ( *)r!& ,e 4(+e !-e3re 'e ,$ )3 e&r $ "(s,-&r4e &3!er &

)r & +&4( & #(r!-


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+LI,I+AL FEAT-RE


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DIAG,OSIS

P-$s(,& E;& ( &!()A !-)'4- s!re*!),),,& !);(, s-), s$ "r) e 3r)GAS ),,'rs +er$ r&re $ ( !-e *)s!*&r!' *er()" (!s*re+& e ,e (s ) !-e r(se re '(r( 4 ( ,re&se"

re,)4 (!() & " s'r+e( & ,e )3 !-e "(se&se & ) 4 &, ( (,(& s ,&r( 4 3)r 7) e ( !-e *'er*er(' .As *r( &r$ *r&,!(!() ers 3)r 7) e ( !-(s *er()"

("7(+es 's! &( !&( &se*!(, !e,- ( 'e e *-&s(>e

*r)*er ,&re & " , e& ( 4 )3 +&4( & !e&rs & " e"',&!e7) e )'! !-e s(4 s & " s$ *!) s )3 ( 3e,!()( , '"( 4 s7e ( 4 er$!-e & "r&( &4e & " *&( &!!-e s(!e )3 !-e 7)' ".


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DIAG,OSIS

L)r&!)r$ B ))" C' !'reA !-)'4- ser) )4(, 4r)'*( 4 #$ !-eL& ,e=e " e!-)" (s !-e ,r(!er()s!& "&r" 3)r "( ere !(&!() )3*&!-)4e (, s!re*!),),,& s*e,(es4r)'* A )r4& (s s ,& #e ("e !(=e"

)re ,)s! e e,!(+e $ #$ ' er)'s&!e; &44 '!( &!() ,)&44 '!( &!() )r

e >$ e ( ' )&ss&$ *r),e"'res


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DIAG,OSIS

STREPTOCOCCUS GROUP A IS DEMONSTRATED INBLOOD AGAR MEDIA


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DIAG,OSIS

S(4 & " S$ *!)S(4 s )3 se*s(s e4 3e+er !&,-$,&r"(&!&,-$* e& -$*)!e s() &$ #e*rese ! ( ( +&s(+e ( 3e,!() s #'! 's'&s$ *!) &$ ),,'r ( e 3e+er /*$re;(& $& 4(& & )re;(& & " 3&!( 'e.

T-e s$ *!) s 's'& $ ),,'r &! 20 "&$s*)s!*&r!' .


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DIAG,OSISStreptococcal Toxic Shock Syndrome

Cr(!er(& *r)*)se" #$ !-e W)r ( 4 Gr)'* ) Se+ereS!re*!),),,& I 3e,!() s 3)r !-e "(&4 )s(s )3s!re*!),),,& !);(, s-), &re )'! ( e" &s 3) )7s < %Is) &!() )3 4r)'* A Streptococcus 6 Fr) & s!er( e s(!e )r

3r) & ) s!er( e #)"$ s(!eC ( (,& s(4 s )3 se+er(!$ 2 )r )re )3 !-e 3) )7( 4, ( (,& & " )r&!)r$ )r & (!(es &re re '(re" 6Re & ( *&(r e ! ,)&4' )*&!-$ (+er )r & (!(es&,'!e res*(r&!)r$ "(s!ress e;!e s(+e !(ss'e e,r)s(s

e,r)!(>( 4 3&s,((!(s er$!-e &!)'s r&s-De= (!e ,&se 6 Is) &!() )3 4r)'* A Streptococcus 3r) &s!er( e s(!e * 's ,) *&!(# e , ( (,& s(4 sPr)# e ,&se 6 Is) &!() )3 4r)'* A Streptococcus 3r) &

) s!er( e #)"$ s(!e * 's ,) *&!(# e , ( (,& s(4 s


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THERAPY

Dr'4 )3 C-)(,e GAS I 3e,!() %Pe (,( (

A er4( !) Pe (,( ( % Er$!-r) $,( )r& )!-er &,r) ("e

Or& e;!e "e"6s*e,!r' 2 "/9r"4e er&!() ,e*-*& )s*)r( s & !-)'4-,e=;( e &$ #e s'#)*!( &


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THERAPY

Tre&! e ! 7(!- & *(,( ( / s' #&,!&& );(,( ( / , &+' & (, &,(" )r, ( "& $,(

I ,&ses )3 s!re*!),),,& !);(, s-),s$ "r) e !re&! e ! ,) s(s!s )3 -(4-")se )3 *e (,( ( & " , ( "& $,(4(+e 7(!- ( !r&+e )'s ( ' )4 )#' (


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PROG,OSIS

S & r(s )3 re,'rre ,e ( s'#se 'e !*re4 & ,(es

Be!!er -& " -(4(e e & " s& (!&!() & "& s) 4))" )3 ( ' ,) "(!() (s re '(re"!) *re+e ! GAS I 3e,!()


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CONCLUSIONS

:5


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Pre4 & ,$ (s & -(4- $ ( ' ) )"' &!e" s!&!e!-&! *er (!s ( * & !&!() & " "e+e )* e ! )3!-e ( ' ) )4(,& $ "(s!( ,! 3e!'s.

T-(s &$ res' ! ( & ( ' ) )4(,& $+' er e FRT !-&! (s )re e&s( $ ( 3e,!e"&3!er "e (+er$.

T-e ( ' e ,-& 4es *r)4ress "'r( 4*re4 & ,$ % ,) * e; & " re &( &r4e $' ,-&r&,!er(>e"


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Re,e ! rese&r,- s'44es!s GAS ( 3e,!() s

&re re6e er4( 4P)s!*&r!' *&!(e !s &re *&r!(,' &r $ *r) e!) se+ere GAS ( 3e,!() s !-&! res' ! ("e&!-

T-e e,-& (s s #e-( " GAS #&,!er(&+(r' e ,e *)s!*&r!' s's,e*!(#( (!$ & "!-e ( ' e res*) se !) FRT ( 3e,!() s

re &( *))r $ ' "ers!))" & " 3'!'re 7)r's! #e ") e !) &""ress !-e ( ,re&se (&!er & )r!& (!$ 3r) *)s!*&r!' GAS

( 3e,!() s.:@


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Referat R4