The Historical Evolution of Streptococcal Complications of Varicella • 767

Abstract

Recent reports have emphasized invasive infections with Group A beta hemolytic streptococci (GABHS) complicating varicella, including sepsis, necrotizing fasciitis (NF), and streptococcal toxic shock syndrome (STSS). To assess the evolution of the relationship between GABHS and varicella, relevant literature from 1767 to 1996 was analyzed. Three discrete eras characterize the relationship between GABHS and varicella: I. Pre-antibiotic Era(1767-1945); II. Early antibiotic Era (1945-1975); and III.Late antibiotic Era (1976-1996). In Era I, Heberden's description of varicella in 1767 noted some patients with a malignant sort, with high fever and larger, redder pox lesions. Following Pasteur's discovery of streptococci in 1870, hemolytic streptococci emerged as the major bacteria complicating varicella, and many reports as early as 1807 described children with varicella complications closely resembling later descriptions of NF and STSS. Prior to availability of Lancefield serogrouping of streptococci, Bullowa and Wishik reported beta streptococci to be the major cause of bacterial complications of varicella, including sepsis, cellulitis, adenitis, erysipelas, abscesses, empyemas, and gangrene, from 1929-1933 in New York City. In Era II, virtually no reports of GABHS complications of varicella were published during the first three decades after the introduction of antibiotics. However, in the late 1970's (Era III), reports began to document an apparently increasing number of severe GABHS infections complicating varicella. Such reports have become particularly numerous in the past decade and coincide with an apparent increase in severe pediatric and adult GABHS infections unassociated with varicella. Ontario data from 1992-1993 documented an invasive GABHS infection rate in those ≤10 years old with varicella = 4.4/100,000, with a relative risk within two weeks after varicella = 39 (p<0.001). The resurgence of GABHS complications of varicella has occurred despite no change in the universal sensitivity of GABHS to beta-lactams nor in severity of primary varicella per se. Rather, this likely reflects increased virulence of certain GABHS strains related to production of one or more pyrogenic exotoxins and the possible influence of environmental factors such as use of non-steroidal anti-inflammatory agents. Resurgent serious GABHS complications of varicella highlight the desirability of widespread use of the varicella vaccine.