Reports of resurgence in invasive group A streptococcal (GAS) infections come mainly from affluent populations with infrequent exposure to GAS. In the Northern Territory (NT) of Australia, high incidence of invasive GAS disease is secondary to endemic skin infection, serotype M1 clones are rare in invasive infection, the diversity and level of exposure to GAS strains are high, and no particular strains dominate. Expression of a plasminogen-binding GAS M-like protein (PAM) has been associated with skin infection in isolates elsewhere (D. Bessen, C. M. Sotir, T. M. Readdy, and S. K. Hollingshead, J. Infect. Dis. 173:896-900, 1996), and subversion of the host plasminogen system by GAS is thought to contribute to invasion in animal models. Here, we describe the relationship between plasminogen-binding capacity of GAS isolates, PAM genotype, and invasive capacity in 29 GAS isolates belonging to 25 distinct strains from the NT. In the presence of fibrinogen and streptokinase, invasive isolates bound more plasminogen than isolates from uncomplicated infections (P < 0.004). Only PAM-positive isolates bound substantial levels of plasminogen by a fibrinogen-streptokinaseindependent pathway (direct binding). Despite considerable amino acid sequence variation within the A1 repeat region of PAM where the plasminogen-binding domain maps, the critical lysine residue was conserved.Group A streptococci (GAS) cause a variety of superficial infections, such as impetigo, as well as invasive diseases, including bacteremia, necrotizing fasciitis, and myositis. A recent survey from the tropical "Top End" of the Northern Territory (NT) found a high incidence of invasive GAS disease, with rates of bacteremia in non-Aboriginal people (8) comparable to those that constituted the resurgence in GAS bacteremia described elsewhere in the Western world (29,39). Among Aboriginal people of the Top End, the incidence of GAS bacteremia is five times that of non-Aboriginal people living in the same region (8).In addition to the high incidence of severe GAS infection in the NT, several other epidemiological features characterize the GAS isolates from this vast geographic region. Up to 60% of isolates from the NT do not react with available M-typing sera (28), while some react with more than one, giving an ambiguous M-typing result (27). This has led to the development of the vir typing system, which consists of restriction fragment length polymorphism analysis of the mga regulon (14). vir typing of strains that cause GAS infection in Aboriginal communities has demonstrated that the diversity and turnover rate of these strains are much higher than those reported elsewhere (7). There has been no evidence of a resurgence in severe invasive infections due to particular strains or any invasive infection associated with M1 clones (8), which have been responsible for much of the recent resurgence in GAS bacteremia reported elsewhere (31). A recent NT study examining 100 GAS isolates found only two M1 isolates which were not clonally related or isolated fro...