Letter to the Editor
Outbreak of group A streptococcal pharyngitis at a national sports competition in Montevideo, Uruguay
Brote de faringitis por estreptococo grupo A en una competencia deportiva nacional en Montevideo, Uruguay
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Imagen obtenida con un microscopio de epifluorescencia Nikon Eclipse Ti, equipado con objetivo de inmersión 60×, apertura numérica 1,40, filtro Nikon G-2A. Se empleó una cámara DS-QI1MC Nikon Digital Sight, acoplada al software analizador de imágenes NIS-Element F.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Silvana M. Díaz Herrera, Florencia J. Rossello, María P. Benavides, María D. Groppa, Myriam S. Zawoznik" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Silvana M." "apellidos" => "Díaz Herrera" ] 1 => array:2 [ "nombre" => "Florencia J." "apellidos" => "Rossello" ] 2 => array:2 [ "nombre" => "María P." "apellidos" => "Benavides" ] 3 => array:2 [ "nombre" => "María D." "apellidos" => "Groppa" ] 4 => array:2 [ "nombre" => "Myriam S." 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Southernmost record in the world" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "197" "paginaFinal" => "200" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aporte al conocimiento de los hongos patógenos de arañas en Argentina. El registro más austral del mundo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1243 "Ancho" => 1651 "Tamanyo" => 113763 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Conidia and phialides of <span class="elsevierStyleItalic">Purpureocillium lilacinum</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Romina G. Manfrino, Alda González, Jorge Barneche, Julieta Tornesello Galván, Nigel Hywell-Jones, Claudia C. López Lastra" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Romina G." "apellidos" => "Manfrino" ] 1 => array:2 [ "nombre" => "Alda" "apellidos" => "González" ] 2 => array:2 [ "nombre" => "Jorge" "apellidos" => "Barneche" ] 3 => array:2 [ "nombre" => "Julieta" "apellidos" => "Tornesello Galván" ] 4 => array:2 [ "nombre" => "Nigel" "apellidos" => "Hywell-Jones" ] 5 => array:2 [ "nombre" => "Claudia C." "apellidos" => "López Lastra" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0325754116301250?idApp=UINPBA00004N" "url" => "/03257541/0000004900000002/v1_201706021206/S0325754116301250/v1_201706021206/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Outbreak of group A streptococcal pharyngitis at a national sports competition in Montevideo, Uruguay" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "201" "paginaFinal" => "202" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gabriela García Gabarrot, Eugenia Torres Debat, Grisel Rodriguez, Mónica Castro, Gustavo Gagliano, Teresa Camou" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Gabriela García" "apellidos" => "Gabarrot" "email" => array:1 [ 0 => "ggarcia@msp.gub.uy" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eugenia Torres" "apellidos" => "Debat" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Grisel" "apellidos" => "Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Mónica" "apellidos" => "Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Gustavo" "apellidos" => "Gagliano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "Teresa" "apellidos" => "Camou" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Laboratorios, Ministerio de Salud, Montevideo, Uruguay" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CASMU, Montevideo, Uruguay" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sanatorio Americano, Montevideo, Uruguay" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Vigilancia en Salud, Ministerio de Salud, Montevideo, Uruguay" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de faringitis por estreptococo grupo A en una competencia deportiva nacional en Montevideo, Uruguay" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1936 "Ancho" => 1626 "Tamanyo" => 268258 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Geographical distribution of clinical cases of tonsillo-pharyngitis/participants at the national competition, by district. The green squares depict districts where GAS isolates were obtained. The red square points at the capital city where no isolates or cases were identified.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Group A streptococci (GAS) has been reported as an unusual cause of food-borne outbreaks in industrialized countries, causing pharyngitis and differing from air-borne outbreaks in that they begin abruptly and have low complications rate<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In November 2013, a large GAS outbreak was reported among 1702 young participants (15–20 years old) from all over the country who came to Montevideo, the capital city of Uruguay, for a sports competition (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The competition started November 6<span class="elsevierStyleSup">th</span> and 2 days later many competitors became ill and needed medical assistance. At least 374 patients with tonsillo-pharingitis were identified (attack rate 21.97%), most between November 8<span class="elsevierStyleSup">th</span> and 9<span class="elsevierStyleSup">th</span>. The affected competitors were staying together at the same facility but they participated in different sports, were from different geographic origins and slept in different rooms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The epidemic curve suggested an outbreak by a common source, probably food-borne. The meal was provided by a catering service to all participants, except to those living in Montevideo. The epidemiological investigation showed that procedures for preparation, storing, transporting and handling of the dishes were not always according to regulations. One of six food handlers in place tested positive for rapid GAS antigen detection test. Unfortunately, the catering service was not investigated: no food samples were obtained and their food makers were not studied. Interestingly, none of the participants living in Montevideo became ill.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All symptomatic patients were treated with intramuscular penicillin and 2 were hospitalized for febrile seizures and bronchospasm respectively.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Most cases were only clinically diagnosed, thus only 20 GAS throat isolates from patients living in 10 different cities were available for characterization at our institution, the National Reference Laboratory (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Penicillin, erythromycin, clindamycin, tetracycline, cloramphenicol and levofloxacin were tested using disk diffusion following the procedures of Clinical and Laboratory Standards Institute. The <span class="elsevierStyleItalic">emm</span> type was determined by sequencing the variable 5′-end of the <span class="elsevierStyleItalic">emm</span> gene, according to the Centers for Disease Control and Prevention.</p><p id="par0040" class="elsevierStylePara elsevierViewall">PCR was used to detect <span class="elsevierStyleItalic">speA</span>, <span class="elsevierStyleItalic">speC</span>, <span class="elsevierStyleItalic">speB</span> and <span class="elsevierStyleItalic">ssa</span> genes as described previously<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>. PFGE was used to confirm the GAS similarity<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and two random selected isolates were studied by MLST<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">All GAS isolates were susceptible to the antibiotics tested. Indistinguishable PFGE profiles were obtained and only <span class="elsevierStyleItalic">speB</span> was identified in all isolates.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The 20 GAS isolates corresponded to <span class="elsevierStyleItalic">emm</span> type 68.3, a very rare serotype scarcely cited in literature. This <span class="elsevierStyleItalic">emm</span> type was not identified in a previous study of GAS invasive and non- invasive infections, among 135 isolates collected between 1999 and 2012 in Uruguay<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>. To our knowledge, <span class="elsevierStyleItalic">emm</span>68.3 has never been associated with food-borne streptococcal sore throat outbreaks before.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The isolates tested for MLST were ST247, which is represented by only 4 isolates in the MLST database<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In summary, for the first time in Uruguay, a large outbreak of tonsillo-pharyngitis was recorded. This outbreak was caused by a single clone of group A streptococci <span class="elsevierStyleItalic">emm</span>68.3/ST247. Isolates from food were not available for comparison, but the epidemiological features suggest that food could be the source of infection.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1936 "Ancho" => 1626 "Tamanyo" => 268258 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Geographical distribution of clinical cases of tonsillo-pharyngitis/participants at the national competition, by district. The green squares depict districts where GAS isolates were obtained. 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| 2017 October | 5 | 2 | 7 |
| 2017 September | 6 | 1 | 7 |
| 2017 August | 10 | 3 | 13 |
| 2017 July | 12 | 3 | 15 |
| 2017 June | 23 | 8 | 31 |
| 2017 May | 4 | 2 | 6 |
| 2017 April | 4 | 3 | 7 |
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