Can skin infection with group A streptococcus cause acute rheumatic fever?

传统上认为，急性风湿热（ARF）的病因总是喉咙感染A群链球菌（GAS）。然而，在北领地上端的土著社区，据报道ARF的发病率是世界上最高的，然而GAS很少从喉咙分离出来。有进一步的信息表明，气体皮肤溃疡可能是许多ARF病例的基础。如果这一点得到证实，将彻底改变对ARF病因的传统看法，并对世界各地的ARF预防具有重要意义。目前，这些方法侧重于诊断和治疗喉咙痛，但没有任何国家证明这种规划能够成功地大幅减少ARF新发病例。如果人们知道皮肤感染可能导致ARF，那么各国（包括澳大利亚）就可以强调皮肤健康计划的重要性。这种知识的另一个好处是影响GAS疫苗的开发，目前主要集中在预防喉咙痛。最近提出了一种不同的可能性，即ARF的病因可能并不总是GAS，相反，相关细菌GCS和GGS可能具有引起这种疾病的潜力。这一假设的证据甚至会极大地改变我们对疾病病因、预防和疫苗开发的理解。我们建议通过定期擦拭有ARF病史的家庭，并使用皮肤和喉咙拭子中细菌的遗传指纹来确定土著社区ARF的原因。当发生ARF病例时，我们将能够确定导致发作的感染部位和类型。我们将在更多社区开展相关研究，我们将对ARF患者和对照家庭（未发生ARF）的家庭成员进行拭子取样，以确定最常从ARF家族中分离出的细菌。

It is traditionally taught that the cause of acute rheumatic fever (ARF) is always infection of the throat with the bacterium group A streptococcus (GAS). However, in Aboriginal communities of the Top End of the Northern Territory the incidence of ARF is the highest reported in the world, yet GAS is uncommonly isolated from the throat. There is further information to suggest that GAS skin sores may underlie many cases of ARF. If this were proven, it would completely alter the traditional view of the cause of ARF, and have important implications for prevention of ARF around the world. Presently, these approaches focus on diagnosing and treating sore throat, but no country has proven that such a program can be successful in substantially reducing new cases of ARF. If it was known that skin infection could lead to ARF, then countries (including Australia) could emphasise the importance of skin health programs. A further benefit of this knowledge would be to influence GAS vaccine development, which presently is largely focused on the prevention of sore throat. A different possibility has recently been raised - that the cause of ARF may not always be GAS, but instead that the related bacteria GCS and GGS may have the potential to cause this disease. Proof of this hypothesis would even more dramatically alter our understanding of disease causation, prevention, and vaccine development. We propose to determine the cause of ARF in Aboriginal communities by regularly swabbing families of people with a history of ARF, and using genetic fingerprinting of the bacteria from the skin and throat swabs. When cases of ARF occur, we will be able to determine the site and type of infection that precipitated the attack. We will conduct a related study in more communities, in which we will swab family members of people with ARF and of control families (without ARF) to determine the bacteria most commonly isolated from ARF families.