f Acute rheumatic fever (ARF) is a postsuppurative sequela caused by Streptococcus pyogenes infections affecting school-age children. We describe here the occurrence of an ARF outbreak that occurred in Bologna province, northeastern Italy, between November 2012 and May 2013. Molecular analysis revealed that ARF-related group A Streptococcus (GAS) strains belonged to the M-18 serotype, including subtypes emm18.29 and emm18.32. All M-18 GAS strains shared the same antigenic profile, including SpeA, SpeB, SpeC, SpeL, SpeM, and SmeZ. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) analysis revealed that M-18 GAS strains grouped separately from other serotypes, suggesting a different S. pyogenes lineage. Single nucleotide polymorphisms and phylogenetic analysis based on whole-genome sequencing showed that emm18.29 and emm18.32 GAS strains clustered in two distinct groups, highlighting genetic variations between these subtypes. Comparative analysis revealed a similar genome architecture between emm18.29 and emm18.32 strains that differed from noninvasive emm18.0 strains. The major sources of differences between M-18 genomes were attributable to the prophage elements. Prophage regions contained several virulence factors that could have contributed to the pathogenic potential of emm18.29 and emm18.32 strains. Notably, phage ⌽SPBO.1 carried erythrogenic toxin A gene (speA1) in six ARF-related M-18 GAS strains but not in emm18.0 strains. In addition, a phage-encoded hyaluronidase gene (hylP.2) presented different variants among M-18 GAS strains by showing internal deletions located in the ␣-helical and TSH regions. In conclusion, our study yielded insights into the genome structure of M-18 GAS strains responsible for the ARF outbreak in Italy, thus expanding our knowledge of this serotype.
Streptococcus pyogenes, group A streptococcus (GAS), is a Gram-positive bacterium responsible for a wide spectrum of diseases ranging from moderate or mild infections to severe invasive diseases such as necrotizing fasciitis and toxic shock-like syndrome (TSLS). Several GAS infections can cause severe postinfectious sequelae, including acute poststreptococcal glomerulonephritis, acute rheumatic fever (ARF), and rheumatic heart disease (1).ARF is a systemic disorder resulting from an autoimmune disease following a GAS infection that usually occurs in children between 5 and 15 years of age (2). During the last several decades, the incidence of ARF cases has significantly declined in the United States and Western Europe, whereas it remains high in Eastern Europe, Asia, and Australia (3). However, the resurgence of ARF in several geographical areas, including United States, is a matter of concern (4).S. pyogenes possesses different virulence factors such as the M protein and superantigens (SAgs) that contribute to the pathogenesis of GAS infection (1). On the basis of the high variability of the M protein among GAS strains, the 5=-terminal sequence of the emm gene (emm typing) is considered a reliable molecular marke...