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Kindergarten-based outbreak of perianal group A streptococcal infection

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Perianal cellulitis due to group A beta-haemolytic streptococcal infection (PASI) was first reported in 1966. Children are affected much more frequently than adults, and boys more than girls. There is usually a well demarcated perianal rash, often with pain, pruritus, and blood streaked stools but no fever or other systemic symptoms. Relatively little is known about the epidemiology of this disease. Danish workers (

) have reported what they claim is the largest documented outbreak so far.

Cases of perianal erythema and bloody stools were noticed in a kindergarten in a rural community in Denmark beginning in November 1999. The first cases were misdiagnosed as pinworms or thrush but after the diagnosis of PASI was made in one child local practitioners were informed of the diagnosis and advised to take perianal and throat swabs from subsequent cases. Over a 4-month period 17 children had PASI. Twelve of these (11 boys) had an apparently identical strain of group A beta-haemolytic streptococcus (T type 28 and identical profiles on pulsed field gel electrophoresis) grown from perianal swabs. Six of these 12 children attended the kindergarten, four were household contacts of kindergarten children or staff, and only two had no known connection. During the same period five people with PASI (one adult) were infected with different strains of the organism giving an estimated background (non-outbreak) annual incidence of 2–7 per 1000 children. Initially treatment with oral penicillin V failed in three children but all children responded to oral clarithromycin.

This outbreak was apparently caused by a single clone of group A beta-haemolytic streptococcus. Treatment with clarithromycin was effective. The infection may be more common than has been realised.

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