Skin and soft tissue infections- Kozel Flashcards
1
Q
(blank) is any skin infection that is pyogenic
A
pyoderma
2
Q
Primary pyoderma can be (blank) or (blank)
A
purulent or non-purulent
3
Q
What is this:
-vesicular, later crusted, superificl infection of skin
A
impetigo
4
Q
What causes non-bullous impetigo?
A
- streptococcus pyogenes (20-30%)
- staphylococcus aureus (now most common)
- mixed infection
5
Q
What is this:
begins as erythematous papules that evolve into vesicles and pustules that rupture
Dries to form honey-colored crusts on erythematous base
typically heals without scars
A
Impetigo
6
Q
What causes bullous impetigo?
A
strain of s. aureus producing exfoliating toxin.
7
Q
What does the toxin of bullous impetigo do?
A
cleaves dermal-epidermal junctions
8
Q
What is ecthyma?
A
deeper form of impetigo that presents as ulcerative pyoderma of skin
9
Q
Ecthyma follows (blank) or (blank)
A
insect bits
minor trauma
10
Q
What bacteria causes ecthyma?
A
S. aureus and/or S. pyogenes
11
Q
Does ecthyma heal with scars or no scars?
A
scars
12
Q
What is this:
collections of pus within dermis and deeper tissue
A
Cutaneous abscess
13
Q
What bacteria causes cutaneous abscesses?
A
S. aureus, can be polymicrobial
14
Q
What are all the purulent primary pyodermas?
A
-cutaneous abscess
-folliculitis, carbuncles, furuncles
-chancriform leions
-
15
Q
What is this:
pyoderma located wtihin hair folicle
A
folliculitis
16
Q
What is this:
inflammatory nodule extending into subcutaneous tissue; follows folliculitis
A
Furuncle (boil)
17
Q
What is this:
coalescent process involving multiple follicles
A
carbuncle
18
Q
What is the etiology of folliculitis, carbuncles, and furuncles?
A
S. aureus
19
Q
What kind of lesions are chancriform lesions?
A
ulcerative lesion
20
Q
Cutaneous anthrax and venereal infections are forms of (blank) lesions.
A
chancriform
21
Q
What is this:
- direct inoculation with bacillus anthracis
- begins as painless pruiritic papule; enlarges, vesiculates (malignant pustule), becomes necrotic and covered by eschar
A
Cutaneous anthrax
22
Q
What venereal infections are types of chancriform lesions?
A
treponema pallidum and haemophilus ducreyi
23
Q
What are other infections that can cause chancriform lesions?
A
Franciscella tularensis
Mycobacterium ulcerans
Mycobacterium marinum
24
Q
What are these:
diffuse, superficial, spreading skin infections
A
Erysipelas and cellulitis
25
Is erysipelas and cellulitis associated with collections of pus?
No
26
Purulent lesions (discharging pus) require (blank). (e,g abscess, furuncle, carbuncle)
drainage
27
Cellulitis requires (blank) therapy
antimicrobial
28
(blank) is an infection involving upper dermis and subcutaneous fat
cellulitis
29
When do you get cellulitis?
after trauma, or underlying skin lesion (i.e furuncle or ecthyma)
30
Describe the symptoms of cellulitis
Pain, erythema, involved area very red, hot, and swollen
31
What is the etiology of cellulitis?
Streptococci- Group A and others; less often S. aureus
32
If you see the words trauma, water contact, or animal, insect or human bites?
cellulitis
33
What is this:
superifical cellulitis w/ prominent lymphatic involvement
-painful; sharp demarcation from adjacent normal skin
Erysipelas
34
What is the etiology of Erystipelas?
S. pyogenes
35
What is this:
aggressive subcutaneous infection that tracks along the superficial fascia-all tissues between skin and underlying muscle
necrotizing fasciitis
36
Necrotizing fascitis most often is an extension from a skin (blank)
lesion
37
Necrotizing fasciitis is a (blank) toxicity
systemic
38
What is the etiology of necrotizing fasciitis?
```
S. pyogenes
S. aureus
Vibrio vulnificus
Aeromonas hydrophila
****often polymicrobic****
```
39
What are other clinical forms of subcutaneous tissue infection?
- syngeristic necrotizing cellulitis
- clostridial anaerobic cellulitis
- Misc. infections secondary to trauma
40
What are five systemic bacterial infections that produce rashes or skin lesions
- bacteremia
- leptospirosis
- rat-bite fever
- annular erythema
- rocky mountain spotted fever
41
What causes bacteremia?
S. aureus
Group A streptococcus
N. meningitidis
42
What causes leptospirosis (Weils disease)?
leptospira interrogans
43
What causes annular erythema (lyme disease)?
Borrelia burgdorferi
44
What causes rocky mountain spotted fever?
rickettsia rickettsii
45
What is the rash you see in rat bite fever?
petechial and purpuric lesion
46
What is the rash you see in leptospirosis?
macropapular rash
47
What is the rash you see in lyme disease?
annular erythema
48
What is this:
- follows pharyngitis by group A streptococcus,
- streptococcal pyogenic exotoxin A (SpeA)
Scarlet Fever
49
What is this:
- follows local infection by S. aureus
- Staph exfoliating toxin
Scalded skin syndrome
50
What is this:
- follows infection by staph aureus
- staph TSST-1 superantigen
Toxic Shock syndrome
51
What are the infections following animal contact (6)?
```
Cutaneous anthrax
Cat-Scratch disease
Erysipeloid
Pasteurela multocida
Bubonic plague
Tularemia
```
52
What causes cutaneous anthrax?
bacillus anthracis
53
What causes cat-scratch disease?
bartonella henselase
54
What causes erysipeloid?
erysipelothrix rhusiopathiae
55
What animals cause erysipeloid?
fish, marine animals, swine or poultry
56
What causes pasterurella multocida?
dog or cat bites
57
What causes bubonic plague?
yersinia pestis
58
What causes tularemia?
francisella tularensis
59
What is this:
wound-surgical wounds
source- nosocomial, moist environments
Serrtia marcesens
60
What is this:
wound-cuts and abrasions
source-fresh water
aeromonas spp.
61
What is this:
woud-burns
source-environmental
pseudomonas aeruginosa
62
What is this:
wound-cuts and abrasions
source-brackish and salt water
vibrio parahemolyticus
63
What is this:
wound-battlefield injuries
source-nosocomial
Acinetobacter baumanii
64
What is this:
wound-human bite, fistfight
source- human mouth
Eikenella corrodens
65
What is this:
presence of pus within individual muscle groups
usually S. aureus (90%)
most cases in tropics
Pyomyositis
66
What is this:
- necrotic damage to muscle tissue
- occurs after muscle injury and contamination with soil or other material containing spores
- extreme pain, crepitus due to gas formation, yellowish/bronze discoloration
Myonecrosis/gas gangrene
67
What is the etiology of myonecrosis/gas gangrene?
Clostridium perfringens (most common) and other clostridial species
68
What is this:
The patient is a 6-year-old boy who presented with an apparent skin infection that began as small vesicles that rapidly pustulated and developed thick, golden-yellow crusts shown below. Culture on blood agar is also shown below. Gram stain from the culture is also shown. The patient was treated with cephalex, and the infection resolved over several days.
Three weeks after the infection, the patient developed a generalized edema and hematuria with smoky-colored urine. Physical exam found that the patient was hypertensive. A test for anti-DNAse antibodies was positive
poststreptococcal glomerulonephritis
69
What is this:
catalase negative
gram positive cocci in pairs or chains
typicaly require complex media-blood or serum
Streptococci
70
How do you classify strep?
hemolytic patterns on blood agar
antigenic-lancefield grouping
biochemical (physiological) properties
71
How do you classify beta hemolytic strep?
lancefiled grouping
72
How do you classify alpha and gamma hemolytic strep?
by biochemical testing
73
What is this:
Partial hemolysis - greening of agar
Numerous species: S. salivaris, S. mitis
Normal flora of mucous membranes
alpha hemolytic strep
74
What is this:
Complete hemolysis - clear zone
Streptolysins O and S
beta hemolytic
75
What is this:
No hemolysis
Misc. normal flora, opportunists and anaerobes
Gamma hemolytic or non-hemolytic
76
If you see carbohydrate antigen in cell well then what type of strep do you have?
beta hemolytic strep
77
Most human pathogens belong to group (blank) and is called strep (blank)
A
| pyogenes
78
What groups of strep are normal flora of mucous membranes, occasional pathogens?
B,C,F,G,H,K,L
79
What groups of strep are in lower animals?
E, M, N
80
What group of strep is enterococcus, now enteroccucus faecalis
group D
81
Some strep with C. carbohydrate antigen may be (blank), (blank), or (blank)
alpha, beta or gamma
82
What diseases does S. pyogenes cause?
pharyngitis, pyoderma, rheumatic fever
83
What is the hemolytic pattern of strep pyogenes and what is the serological classification?
beta
| A
84
What is the hemolytic pattern of strep agalactiae and what is the serological classification?
Beta
| B
85
What diseases does S. agalactiae cause?
neonatal sepsis, meningitis
86
What is the hemolytic pattern and serological classification of strep agalactiae?
beta
| B
87
What diseases does S. anguinosus, S. equi, etc. cause?
puerperal sepsis, enocarditis
88
What is the hemolytic pattern and serological classification of s. anginosus, S equi etc?
Beta
| C
89
What diseases doesE. faecalis, E. faecium, E. durans (enterococci); S. bovis, S. equinus; (nonenterococci) cause?
endocarditis, UTI
90
What is the hemolytic pattern and serological classification of E. faecalis, E. faecium, E. durans (enterococci); S. bovis, S. equinus; (nonenterococci)?
Alpha, beta, or nonhemolytic
| D
91
What diseases does S. pneumoniae cause?
pneumonia, otitis media, meningitis
92
What is the hemolytic pattern of S. pneumonia?
alpha
93
What diseases does S. mutans group, S. salivaris group, S. mitis group, etc cause?
subacute endocarditis
94
What is the serological classification and hemolytic patterns of S. mutans group S. salivaris group, S. mitis group?
none or viridans group
| Alpha or nonhemolytic
95
What is the lancefield carbohydrate?
C carbohydrate
96
What does the lancefied carb show you?
S. pyogenes (since all are group A)
| polymer of rhamnose and N-acetyl-glucosamine
97
Where in the cell do you find Lancefield carb (c carb)?
in matrix of cell wal
98
What is this:
- type specific
- subdivides group A into > 100 types
- induces type-specific protective immunity
M protein (found in S. pyogenes)
99
What are the extracellular enzymes found in S. pyogenes?
streptolysin O, DNAse, hyaluronidase
100
What are these caused by:
- pharyngitis
- skin and wound infections
- bacteremia
- toxemia
- non-suppurative disease (post strep sequelae)
Group A strep infections
101
What are the skin and wound infections of group a Strep infections?
impetigo
erysipelas
cellulitis
myositis and necrotizing fascitis
102
What is this:
| colonization of healthy skin; infection via minor trauma
impetigo
103
What is this:
| dermal infection with spreading erythema and edema
erysipelas
104
What is this:
| skin infection that involves subcutaneous tissue
cellulitis
105
WHat is this:
| skin infection that involves deep subcutaneous tissues, destruction of muscle and fat
myositis and necrotizing fasciitis
106
What are the two types of toxemia that Group A strep infections cause?
- Scarlet fever
| - Toxic shock-like syndrome (TSLS)
107
What are the 2 types of non-suppurative disease -post-strep sequalae caused by Group A strep infections?
glomerulonephritis
| Rheumatic fever
108
What are the four virulence factors associated with adherence?
Lipoteichoic acid
F protein
M protein
Hyaluronic acid capsule
109
What does lipoteichoic acid do?
adhesion to epithelial cells
110
What does F protein do?
binds fibronectin, adhesions to nasopharyngeal epithelial cells (sfbl -streptococcal fibronection binding protein I)
111
What does M protein do?
binds to epithelial cells
112
What does hylauronic acid capsule do?
facilitates adhesion to nasal mucosa
| essentia for early colonization
113
What are the 2 virulenc factors that avoid phagocytosis?
Hylaruonic acid capsule
| M protein
114
What is this:
- antiphagocytic
- essential for virulence
- induces solid type-specific immunity; >100 types
- Candidate for vaccine development
M protein
115
Streptococcal pyrogenic exotoxins (Spe) can cause (blank) (blank) and (blank)
rash of scarlet fever
Toxic shock like syndrome (TSLS)
Superantigens
116
What are other names for streptococcal pyrogenic exotoxins (Spe)?
Erythrogenic toxin, scarlet fever toxin
117
What do superantigens of strep pyrogenes cause?
release of IL-1, IL-2, IL-6, TNF-alpha, IFN-gamma
118
Streptococcal pyrogenic exotoxins are coded by (blank)
lysogenic bacteriophage
119
What is this:
| activates steps in inflammation and septic shock (e.g. complement cascade, cytokine secretion, coagulation cascade)
Lipoteichoic acid
120
what are the virulence factors that cause tissue damage and spreading?
- Streptolysin O
- Streptolysin S
- Streptokinase
- Streptodornase
- Hyaluronidase
121
What is this:
| porin; oxygen labile, antigenic, anti-streptolysin O (ASO)
streptolysin O
122
What is this:
| Oxygen stable; non-antigenic
Streptolysin S
123
What is this:
| converts plasminogen to plasmin; lyses blood clots
Streptokinase
124
What is this:
| DNAse; reduces viscosity of abscess material
Streptodornase
125
What are these characteristics of:
strawberry tongue-> enlarged fungiform papillae
Red cheeks and pale area around the mouth
-fine, red, and rough-textured, blanches upon pressure
Rash of scarlet fever
126
What is the exotoxin that causes fever, rash , systemic effects due to the release of superantigens that stimulate cytokine release of IL-1, IL-2, IL-6, TNF-alpha and INF-gamma
SpeA
127
Where is the site of infection for rheumatic fever? Tell me about it
pharynx
prior sensitization
repeated attacks are common
need prophylaxis
128
Where is the site of infection for acute glomerulonephritis? Tell me about it
```
skin
repeated attacks are rare
nephritogenic strains M protein
complement levels decreased
caused by immune complex problem
```
129
When do you get your specimen and what do you take?
before antibiotics
| throat swab, pus, blood
130
What are the 2 ways to do direct examination for strep?
gram staining
| quick strep test
131
Hows does the quick strep test work?
lateral flow technology
| detects lancefield carbohydrate antigen
132
What kind of isolation do you use for strep?
blood agar
133
What are the differential tests for strep?
```
Gram positive coccus
Beta hemolytic
Catalase negative
Bacitracin sensitive
Tests for Lancefield Group-specific antigen
```
134
When do you use serological tests?
for retrospective diagnosis
135
What are the 2 available assays for serologic testing?
Anti-streptolysin O
| Anti-DNase
136
What is this:
typically negative in patients with skin infections
useful for diagnosis of rheumatic fever
not helpful with glomerulonephritis
Anti-streptolysin O
137
What is this:
antibodies produced after skin infection
particularly useful if glomerulonephritis is suspected
Anti-DNase
138
Do serological tests imply immunity to infection?
no
139
How do you transmit pharyngitis?
via airborne droplets
140
How do you transmit skin infection?
by direct contact (hygiene is a major factor)
141
What is immunity to strep like
long term (decades) type-specific immunity due to M protein
142
How do you control strep?
prompt and complete treatment; eliminate carriers
143
How do you treat strep infection?
penicillin (all strains sensitive prompt use reduces antibody response, essential that infection be treated quickly and completely)
144
What are some issues associated with strep infection treatment?
possible mixed infection
necrotizing fasciitis
allergy
risk for rheumatic fever
145
If you have mixed infection such as S. aureus presenting with your strep how should you treat this?
with oxacillin or vancomycin
146
How do you treat necrotizing fasciitis?
high dose penicillin + clindamycin
| need for drainage and surgical debridement
147
How should you treat step if you have an allergy to penicillin?
clindamycin or a narrow spectrium cephalosporin; perhaps a macrolide-check current AHA recommendations
148
What should you do for rheumatic fever?
antibiotic prophylaxis
149
Is it common to have MRSA as a monomicrobial cause of necrotizing fasciitis?
no, it is rare
150
What are the 2 species of staph that are important?
staph aureus
| coagulase negative staph (i.e staph epidermis and other staph species)
151
What are the general features of staph?
- gram positive cocci in grape like clusters
- aerobic
- catalase positive
- may have golden pigment
- beta or non-hemolytic (depends on hemolysins)
152
Is staph highly susceptible to physical and chemical agents?
no it is relatively resistant to these things
153
Staph carries mutiple plasmids and bacteriophages such as (blank and blank)
```
penicillinase (beta lactamase)
Toxin production (enterotoxin, toxic shock, etc.)
```
154
(blank) percent of the S. aureus genome is a core genome conserved among all staph species and strains. The reaminder of genome is mobile DNA (mobile genome)
80
155
What are the mobile DNA components of staph?
bacteriophage
plasmids
transposons
staph chromosomal cassette (much like a transposon)
156
What is the function of mobile DNA?
virulence factors
| antibiotic resistance
157
How are the mobile DNA components of staph regulated?
operon-like
| ex, accessory gene regulator (agr) -quorum sensing
158
What are the infections of skin and subcutaneous tissues caused by staph aureus?
- Impetigo-bullous and pustular
| - Abscesses, folliculitis, furuncles, and carbuncles
159
S. aureaus accounts for (blank) pecent of impetigo (bullous and pustular type) the reamined is caused by s. pyogenes alone or in combo with s. aureus
80%
160
What are the deep infections associated with S. aureus?
- bacteremia
- osteomyelitis and septic arthritis
- pneumonia
- staph enterocolitis (follows upset of normal flora by broad spectrum antibiotics)
161
What diseases are caused by staph toxins?
- food poisoning
- scalded skin syndrome and bullous impetigo
- toxic shock syndrome
162
Is staph highly virulent?
no, it is weakly virulent
| minimal infecting dose large, predisposing conditions
163
What are the lesions like in staph?
suppuration, irreversible tissue damage, scarring
164
What are the structural components associated with staph?
capsule
peptidoglycan and lipoteichoic acids
Protein A
165
What is the capsule like in staph?
antiphagocytic, made up of type 5 or 8
166
The peptidoglycan and lipoteichoic acids in staph contributes to (blank)
inflammation
167
Protein A found in staph has a high affinity for (blank)
IgG Fc fragment
168
What are the enzymes associated with staph?
coagulase
catalase
penicilinase
169
What does this:
converts fibrinogen to fibrin; helps localize lesions
marker for species
Coagulase
170
(blank) facilitates intracellular survival in staph
catalase
171
What are the cytotoxins associated with staph?
alpha, beta delta and gamma toxins, P-V leukocidin
| (toxic via various mechanisms for erythrocytes, leukocytes, and platelets
172
Where do you see exfoliatin toxin (ETA and ETB)?
scalded skin syndrome
173
What are the three pyrogenic exotoxins for staph?
superantigens
staph enterotoxin
toxic shock syndrom toxin (TSST-1)
174
(blank) are encoded by plasmids (enterotoxins) or bacteriophage (TSST)
pyrogenic exotoxins
175
(blank) induce release of IL-1, TNF alpha, and other toxins. Related to strep pyrogenic exotoxins. Have specific toxic activities distinct from superantigen effects.
Superantigens
176
What are some staph enterotoxins?
(SEA SEB SEC SED SEE)
177
What is this;
- ingestion of preformed staph entertoxin
- resistant to heat (boiling for 30 min) and gastric enzymes
- targets sensory nerve endings in SM of intestine
- nausea, cramps, vomiting, diarrhea
- recovery in 24 hr
Staphylococcal food poisoning
178
What is this:
toxemia, bulous impetigo is local form, toxin is a serine protease, cleaves dermal-epidermal junction to form fragile, thin roofed vesicopustules, usually in children
Staph scalded skin syndrome
179
(blank) is an infection at distant site with release of exoliating toxin in staph scalded skin syndrome
toxemia
180
What toxin is found in staph scalded skin syndrome?
serine protease
181
What is another name for staph scalded skin syndrome?
exfolitive skin disease
182
the toxemia in this disease produces fever, vomiting, diarrea, rash and shock
staph toxic shock syndrome
183
What is the possible mechanism behind staph toxic shock syndrome?
induction of cytokine release IL-1 and TNF alpha
increased susceptibility to endogenous endotoxin
direct effects on vascular endothelial cels
184
TSST-1 production stimulated by poor (blank)
growth conditions
185
What are the blood cultures like in staph toxic shock syndrome?
negative
186
What are the effects of TSST-1?
fever, systemic effects
187
What is the mechanism behind TSST-1?
superantigen: cytokine release: IL-1, IL-2, IL-6, TNF-alpha, INF-g
188
What are the specimens you need to get for lab ID of staph ?
pus, purulent fluids, throat, nasal and np swabs, urine etc.
189
How can you do directly examine for staph?
pus and CSF
190
What should you isolate staph on?
blood agar or selective media (mannitol salt agar)
191
What are the differential characteristics of staph?
gram positive coccus
catalase positive
coagulase positive
ferments mannitol
192
How can you recognize MRSA?
- chromogenic media with disks of oxacillin or cefoxitin
| - PCR for mecA
193
What is essential in staph and MRSA lab studies?
antibiotic sensitivity testing
194
T or F
| Interpretation of positive culture report depends on source of specimen and clinical judgement.
T
195
Why do you do subspecies typing?
to identify epidemic strains
196
How do you approach subspecie typing?
antibiotic sensitivity patterns (antibiograms)
biochemical profiles (biotyping)
suscpetibility to bacteriophage (phage typing)
nucleic acid analysis
197
(blank) is the primary resevor of staph.
Humans
198
Staph is part of the normal flora of lower (blank), (blank) and (blank)
large bowel
skin
anterior nares
199
How are staph infections acquired?
air (wound infection)
direct contact
endogenous
200
Carrier rate of staph my be (blank) in normal pop and higher in hospital
30%
201
Is there immunity to staph?
no therfore reinfection is common and there is no vaccine
202
How can you decontaminate skin staph?
mupirocin
203
How do you treat staph?
drain lesion; remove foreign body if present
contral underlying diease
antibiotics
204
What are some good drugs to use against staph?
```
Penicillinase-resistant penicillins, e.g., oxacillin
Clindamycin
TMP-SMX
Doxycycline
Linezolid
Vancomycin
Daptomycin
```
205
What are the common ways you get antibiotic resistance with staph?
penicillinase producing S. aureus (very common)
Rsistance to intermediate levesl of vancomycin (VISA)
vancomycin resistan S. aureus (VRSA
206
What is VISA?
Thicker, more disorganized cell wall with free ala-ala groups
Acts as a decoy for vancomycin
207
What is VRSA?
Due to vanA gene operon – encodes ala-lactate production
Requires rigorous susceptibility testing
Still relatively rare
208
Where does MRSA lie?
on a mobile genetic element called SCCmec (staph chromosome cassette)
209
What makes up SCCmec?
```
regulate genes (negative repressor operon)
-mecA
```
210
What is MecA?
encoded PBP 2a w/ low affinity for beta lactam antibiotics
211
what is this:
Associated with risk factors, e.g., surgery, indwelling catheter, etc.
Multi-resistant
Health care-associated MRSA (HCA-MRSA)
212
```
What is this:
No/limited risk factors
Most common cause of skin and soft tissue infections in community
Usually carries the PV leukocidin
Pauci-resistant
```
Community-associated MRSA (CA-MRSA)
213
how do you control staph infection?
decolonization of colonized patients or carriers – 1 week of body washing with chlorhexidine + nasal mupirocin
214
```
The patient is a 6-year-old male who complained of pharyngeal pain and had a temperature of 101°F. The pharyngeal membrane was fiery red, and a thick exudates covered the pharyngeal membrane and tonsillar area. A quick test for Streptococcus pyogenes antigen was positive. The patient will likely develop a protective antibody-based immunity to the specific serotype of the infecting strain. What is the antigen recognized by this protective antibody?
A) Streptococcal M protein
B) Lancefield group A carbohydrate
C) Streptococcal hyaluronic acid capsule
D) Cell wall peptidoglycan
E) Streptolysin O
```
A
215
A culture of skin lesions from a patient with pyoderma (impetigo) shows numerous colonies surrounded by a zone of beta-hemolysis on a blood agar plate. A gram-stained smear from the lesion shows gram-positive cocci. A catalase test of a beta-hemolytic colony is positive. Which of the following bacteria is the most likely cause?
```
A) Streptococcus pyogenes
B) Staphylococcus aureus
C) Staphylococcus epidermidis
D) Viridans streptococcus
E) Staphylococcus saprophyticus
```
| A) Streptococcus pyogenes
216
```
Scarlet fever is a potential complication of streptococcal pharyngitis. The clinical signs of scarlet fever could be blocked by administration of antibody to this bacterial product.
A) Peptidoglycan
B) Teichoic acid
C) Lancefield C carbohydrate
D) Streptolysin O
E) Streptococcal pyrogenic exotoxins
```
E
