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'''Streptococcus''' is a genus of [[gram-positive|gram-positive bacterium]]<ref name="MSD">{{Cite web|url=https://www.msdmanuals.com/professional/infectious-diseases/gram-positive-cocci/streptococcal-infections | title = Streptococcal Infections - Infectious Diseases|website=MSD Manual Professional Edition|language=en|access-date=2020-08-23}}</ref><ref name="Patterson1996">{{Cite book | last = Patterson | first = Maria Jevitz | date = 1996 | editor-last = Baron|editor-first = Samuel | title = Streptococcus|url=http://www.ncbi.nlm.nih.gov/books/NBK7611/|location=Galveston (TX)|publisher=University of Texas Medical Branch at Galveston|isbn=978-0-9631172-1-2|pmid=21413248}}</ref> belonging to the phylum [[firmicutes]] and the order [[lactobacillales]] (lactic acid bacteria). Streptococcus is a d-lactic acid producing bacteria. Excessive production of d-lactic acid can lead to lactic acidosis.<ref name=":1" /> ''Strep throat'' (streptococcal pharyngitis) is caused by group A Streptococcus, with common symptoms including sore throat, fever, and swollen lymph nodes in the neck.<ref name=":0">{{Cite web|url=https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html | title = Group A Strep {{!}} Strep Throat {{!}} For Clinicians {{!}} GAS {{!}} CDC | date = 2019-04-19 | website = [[Centers for Disease Control and Prevention]]|language=en-us|access-date=2020-08-21}}</ref> Strep throat typically resolves in just 1-2 weeks, often without treatment. In ME/CFS, studies have found microbiota overgrowth of Streptococcus species, as well as conditions resulting from this bacterial imbalance (e.g. SIBO, acidosis, dysbiosis), in patients with CFS symptoms.<ref name=":1" /><ref name=":2" /><ref name=":3" /><ref name=":4" /> == D-Lactic Acidosis == Streptococcus and Enterococcus are two aerobic Gram positive intestinal bacteria that produce D-lactate. Elevated levels of [[D-lactic acid]] can lead to [[Lactic acidosis]], characterized by the buildup of lactic acid in the [[Blood|bloodstream]].<ref name=":0" /><ref name=":1">{{Cite journal | last = Sheedy | first = John R. | last2 = Wettenhall | first2 = Richard E.H. | last3 = Scanlon | first3=Denis | last4 = Gooley | first4 = Paul R. | last5 = Lewis | first5 = Donald P. | last6 = Mcgregor | first6 = Neil | last7 = Stapleton | first7 = David I. | last8 = Butt | first8 = Henry L. | last9 = Meirleir | first9 = Kenny L. De | date = 2009-07-01 | title = Increased D-Lactic Acid Intestinal Bacteria in Patients with Chronic Fatigue Syndrome|url=http://iv.iiarjournals.org/content/23/4/621|journal=In Vivo|language=en|volume=23|issue=4 | pages = 621–628|issn=0258-851X|pmid=19567398}}</ref> === CFS symptoms === In a 2009 study, a significant increase of Gram positive facultative anaerobic faecal microorganisms were found in 108 CFS patients as compared to 177 control subjects, including Enterococcus faecalis and Streptococcus sanguinis. Results suggest that when Enterococcus and Streptococcus spp. colonization in the intestinal tract is increased, the resulting excess D-lactic acid alters the pH and gut integrity, and heightens [[intestinal permeability]], allowing the acid into the body. This in turn could explain neurocognitive and mitochondrial dysfunction symptoms in ME/CFS.<ref name=":1" /> == SIBO and Gut Dysbiosis == Streptococcus is often implicated in a condition called [[small intestinal bacterial overgrowth (SIBO)]], characterized by excessive bacteria in small intestines. SIBO is commonly found in ME/CFS, where symptoms often improve after treatment.<ref name=":2">{{Cite journal | last = Pimentel | first = Mark | last2 = Hallegua | first2 = David | last3 = Chow | first3 = Evelyn J. | last4 = Wallace | first4 = Daniel | last5 = Bonorris | first5 = George | last6 = Lin | first6 = Henry C. | date = 2000-04-01 | title = Eradication of small intestinal bacterial overgrowth decreases symptoms in chronic fatigue syndrome: A double blind, randomized study|url=https://www.gastrojournal.org/article/S0016-5085(00)83765-8/abstract|journal=Gastroenterology|language=English|volume=118|issue=4|pages=A414|doi=10.1016/S0016-5085(00)83765-8|issn=0016-5085}}</ref><ref>{{Cite journal | last = Pimentel | first = M | last2 = Wallace | first2 = D | last3 = Hallegua | first3=D | last4 = Chow | first4 = E | last5 = Kong | first5 = Y | last6 = Park | first6 = S | last7 = Lin | first7 = H | date = Apr 2004 | title = A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing | url =https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754959/|journal=Annals of the Rheumatic Diseases|volume=63|issue=4|pages=450–452|doi=10.1136/ard.2003.011502|issn=0003-4967|pmc=1754959|pmid=15020342|quote=|access-date=|via=}}</ref><ref>{{Cite journal | last = Lin | first = Henry C. | date = 2004-08-18 | title = Small Intestinal Bacterial Overgrowth|url=https://jamanetwork.com/journals/jama/fullarticle/199251|journal=JAMA|language=en|volume=292|issue=7 | pages = 852|doi=10.1001/jama.292.7.852|issn=0098-7484}}</ref> The most common bacterial species linked to SIBO include: ''Streptococcus'', ''[[Escherichia coli]]'', ''[[Lactobacillus]]'' and Bacteroides.<ref>{{Cite journal | last = Bouhnik | first = Y. | last2 = Alain | first2 = S. | last3 = Attar | first3=A. | last4 = Flourié | first4 = B. | last5 = Raskine | first5 = L. | last6 = Sanson-Le Pors | first6 = M.J. | last7 = Rambaud | first7 = J.C. | date = Jun 1999 | title = Bacterial populations contaminating the upper gut in patients with small intestinal bacterial overgrowth syndrome|url=https://pubmed.ncbi.nlm.nih.gov/10235214/|journal=The American Journal of Gastroenterology|volume=94|issue=5|pages=1327–1331|doi=10.1111/j.1572-0241.1999.01016.x|issn=0002-9270|pmid=10235214|pmc=|quote=|access-date=|via=}}</ref> SIBO is a manifestation of [[Dysbiosis|microbiome dysbiosis]] (or ''gut dysbiosis''), an imbalance of bacteria in the gut often accompanied by increased levels of [[aerobic bacteria]]<ref name=":1" />, in particular ''Enterococcus'' and ''Streptococcus'' species. === Symptom improvement === A 2015 study found significant symptom and overall sleep quality improvements among ME/CFS patients by treating Streptococcus and microbiota dysbiosis with Erythromycin.<ref name=":3">{{Cite journal | last= Jackson | first = Melinda L. | last2 = Butt | first2 = Henry | last3 = Ball | first3 = Michelle | last4 = Lewis | first4 = Donald P. | last5 = Bruck | first5 = Dorothy | date = Nov 2015 | title = Sleep quality and the treatment of intestinal microbiota imbalance in Chronic Fatigue Syndrome: A pilot study|url=https://pubmed.ncbi.nlm.nih.gov/26779319/|journal=Sleep Science (Sao Paulo, Brazil)|volume=8|issue=3|pages=124–133|doi=10.1016/j.slsci.2015.10.001|issn=1984-0659|pmc=4688574|pmid=26779319|quote= | last6 = | first6 = | authorlink = Melinda Jackson | author-link2 = Henry Butt|access-date= | authorlink3 = Michelle Ball | author-link4 = Donald Lewis | author-link5 = Dorothy Bruck|via=}}</ref> A 2018 study including 44 adult ME/CFS patients ('''all''' with significant ''Streptococcus'' counts) showed improvements in total symptoms, some sleep, and cognitive symptoms following a 4-week Erythromycin + [[Probiotic|probiotic treatment]]. The [[Antibiotics|antibiotic treatment]] was used to target the overgrowth of Streptococcus bacteria found in [[Microbiome|microbiota]] of ME/CFS patients. The idea was based on previous studies linking lactic acidosis and gut dysbiosis with symptoms of ME/CFS. And that d-lactic acid producing bacteria play a large role in both. Results showed antimicrobial and probiotic treatment yielded concurrent reduction in enteric Streptococcus counts and improvement in some neurological symptoms.<ref name=":4">{{Cite journal | last = Wallis | first = Amy | last2 = Ball | first2 = Michelle | last3 = Butt | first3=Henry | last4 = Lewis | first4 = Donald P. | last5 = McKechnie | first5 = Sandra | last6 = Paull | first6 = Phillip | last7 = Jaa-Kwee | first7 = Amber | last8 = Bruck | first8 = Dorothy | date = 2018-02-06 | title = Open-label pilot for treatment targeting gut dysbiosis in myalgic encephalomyelitis/chronic fatigue syndrome: neuropsychological symptoms and sex comparisons|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801817/|journal=Journal of Translational Medicine|volume=16|doi=10.1186/s12967-018-1392-z|issn=1479-5876|pmc=5801817|pmid=29409505}}</ref> == Guttate Psoriasis == Guttate psoriasis is a type of psoriasis that shows up on your skin as red, scaly, small, teardrop-shaped spots. Streptococcal infection is one of the most common triggers of guttate psoriasis, specifically group A streptococcus. <ref>{{Cite web|url=https://medlineplus.gov/ency/article/000822.htm | title = Guttate psoriasis: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2020-08-21}}</ref> In a large 2020 study, CFS patients with [[Human leukocyte antigen genes|Human Leukocyte Antigen]] (HLA) risk alleles were found to share the following [[Autoimmune disease|autoimmune diseases]], ordered by frequency:<ref>{{Cite journal | last = Lande | first = Asgeir | last2 = Fluge | first2 = Øystein | last3 = Strand | first3=Elin B. | last4 = Flåm | first4 = Siri T. | last5 = Sosa | first5 = Daysi D. | last6 = Mella | first6 = Olav | last7 = Egeland | first7 = Torstein | last8 = Saugstad | first8 = Ola D. | last9 = Lie | first9 = Benedicte A. | date = 2020-03-24 | title = Human Leukocyte Antigen alleles associated with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)|url=https://www.nature.com/articles/s41598-020-62157-x|journal=Scientific Reports|language=en|volume=10|issue=1|pages=1–8|doi=10.1038/s41598-020-62157-x|issn=2045-2322}}</ref> # [[Hashimoto's thyroiditis]]/hypothyreosis, # [[Psoriasis]] # [[Rheumatoid arthritis]] # Alopecia areata # Crohn’s disease or [[ulcerative colitis]] == EBV Reactivation == Group A streptococci activate B cells via TLR2 and can trigger lytic reactivation of Epstein-Barr virus (EBV) in tonsils. <ref>{{Cite journal | last = Ueda | first = Seigo | last2 = Uchiyama | first2 = Satoshi | last3 = Azzi | first3 = Tarik | last4 = Gysin | first4 = Claudine | last5 = Berger | first5 = Christoph | last6 = Bernasconi | first6 = Michele | last7 = Harabuchi | first7 = Yasuaki | last8 = Zinkernagel | first8 = Annelies S. | last9 = Nadal | first9 = David | date = 2014-01-15 | title = Oropharyngeal Group A Streptococcal Colonization Disrupts Latent Epstein-Barr Virus Infection|url=https://academic.oup.com/jid/article/209/2/255/826864|journal=The Journal of Infectious Diseases|language=en|volume=209|issue=2|pages=255–264|doi=10.1093/infdis/jit428|issn=0022-1899}}</ref> == Diagnosis == An Antistreptolysin O (ASO) blood test can be used to test for Group A Streptococcus (Streptococcus pyogenes) infection. This test will measure the amount of antibody ASO in the blood. An elevated titer for ASO could indicate active Streptococcus infection. == Treatment== [[File:Erythromycin Resistance.jpg|alt=Erythromycin Streptococcus A Resistance|thumb|The percent of invasive group A Streptococcus (GAS) infections that are resistant to erythromycin has nearly tripled in 8 years. [https://www.cdc.gov/drugresistance/pdf/threats-report/gas-508.pdf CDC Fact Sheet, 2019] |400x400px]] Some ME/CFS patients can improve symptoms by clearing their treatable bacterial infections. There are also viable treatment options for many conditions caused by these infections. === Streptococcus Infection === * Erythromycin * Probiotics * Azithromycin * Penicillin * Amoxicillin * Clindamycin * Clarithromycin Resistance to certain antibiotics is well-documented for group A strep. In many cases, Streptococcus resistance is getting stronger. Be sure to check for the latest updates regarding the effectiveness of specific antibiotics. === D-lactic acidosis === * Intravenous bicarbonate * Clindamycin * Probiotics * Vancomycin * Neomycin * Tetracycline === SIBO === * Rifaximin * Neomycin * Metronidazole * Probiotics == Learn more== * [https://www.msdmanuals.com/professional/infectious-diseases/gram-positive-cocci/streptococcal-infections Streptococcal infections] - Merck manuals ==See also== * [[Human leukocyte antigen genes]] * [[Epstein-Barr virus]] * [[Microbiome]] * [[Small intestinal bacterial overgrowth (SIBO)]] * [[Dysbiosis]] ==References== {{Reflist}} [[Category:Infectious agents]] [[Category:Bacteria]] [[Category:Gram-positive bacteria]]
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