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Recurrent Group C Streptococcal tonsillopharyngitis in an adolescent
tonsillitis. A throat cukure was obtamed. At 48 hours, the cut owed 3+ beta hemolytic S C. Penicihi~, 500 mg four times daily prescribed. Seven days after ~eatme~ d to clinic with a mild sore the clinician to believe t medication was good. Throat cultures was repeated, artd at 48 hcmrs grew 2 + A second course of with the addition of The m3nc spot test was rqative. 8ne week after ent, the patient rerned for a follow-up throat culture. She continued to complain of postnasal drainage and m0rniplg. Physical @xarni~~o~ reveal tiemt with an eryahem sal drip, and ton After consultation with the Pediatric Hnfectious Disease Service, a third course of antibiotics was pre-
Generally considered a wo Group C Streptococcus can be
Group C Streptococcus. I tqcoccus is asymptoomatic. 14-year-old fernale who had beta hemolytic Streptococcus
orrae, Croup C Strepis is a case report of a repeated episodes of Group C pharyngitis.
Case Report A M-year-old Taxmer Stage 5 white female was in good health until she developed a sore throat and difficulty in swallowing of several days duraticm. Physical examination revealed a sick-looking atebrile adolescent with exudative
a 36hour hospitalization. ese symptoms were accomnction tests. Blood cultures panied by elevated liver were sterile, and viral hep s screen as well as titers for cytomegalovirus (CMV), and Epstein43arr (EBV) virus were negative. Over the next 3 months, the patient experienced exacerbations of tonsillopharyngitis. Throat cultures consistently grew Group C beta hemolytic Streptococci sensitive to penicillin and ampicillin. An ASQ titer taken at least t-&e times had been evaluated. In ite of treatment regand oral ampicillin, imens of intramuscular bicillin 1-2 500 mg four times daily for 10 days, the symptoms
persisted.
From the Division of Adolescent Medicine, Dqxartmentof Pediatrics, Idniversity of California San Diego School of Medicine and Medical Center. Address reprint requests to: Maria C. Mwgan, M.D., Division of Adolescent Medicine H 814-F, University ofGl@ornia San Diego Medical Center, 225 Dickinson St., San Diego, CA 92103. hktuscript accepted December 15,1988. Q sodety for Adolescent Medicine. 1989
Further history revealed that the patient had been ing with her pet cat. me patient had a tonsffectomy 6 months later. TOnSiE tissue was sent for aerobic and anaerobic cultures negative for ail organisms inclu month after surgery, a repeat throat culture was still neg421
422
MORGAN AND RICE
ative for beta hemolytic Streptocoscus. The patient has been asymptomatic for over 1 year.
Some key clinical issues conce streptococcus infections are: 1. leukocytosis is tim
Discussion ~&UPC S~~~@~CUCCU~ has been implicated as the
16,
2.
present (3); our patient cause of wound infection, postpartum infection, tom ~ill~pharyngitis, pneumonia, urinary tract infection, osteomyelitis, septicemia, meningitis (X,2), and endocarditis (3). There are four species of Group C Streptococcus: Equisimilis, Str~~cus zouepidemi- 3. dw, Streptwccus qui, and Streptococcus dysgdacth?. Ihe four species are differentiated by their biochemreported. ical properties, host, and pathogenic@ in humans (4) Styqt~s quisimdis is often referred to as the human Streptococcu> C (ti) and is the most comTreatment and ~r~e~tion monly implicated etioiogk agent in humans in idenThe antibiotic of tified Strep C infections. Among the four species, S. penicillin allergy quisidis is the only one that produces streptokichloramphenicol nase and streptolysin 0 (6) The streptokinase prowound infection duced may contribute to its pathogenicity and prevent local and metastic suppura increased virulence (6,7). Animals are a major rescations. ervoir of S. quisimilis Group C Streptococcus and it has been isolated in the pharynx of healthy domestic The authors are grateful to Wayne Danker, M.D., foFMs animals (4). We speculate that our patient’s pet cat advice concerning this patient, to Marianne Felice, M.D., may have been the reservoir for reinfection. editorial comments, and to Dottie McGlone for her manuscript Childhood exanthems such as varicella have been preparation. associated with Streptococcal illness. Swartz et al. reported a case of Streptococcus C epiglottitis in a eferences 9-year-old child with chickenpox (8). The presence of Group C Streptococcus was confirmed by blood 1. Chung S. Meningitis caused by Streptococcus quisimilis. J Uin Path01 1982;79:769. and epiglottis cultures. Noble J, McGowan K. Group C Streptococcal pneumonia in Our patient’s history closely parallelQthat of a ISan adolescenk. Am J Dis Child 1983;137:1023. year-old male with recurrent Group C Stqtococcal Mohr D, Feist D, Washington J, et al. onsduetogroup tonsillitis reported by Fulginitti (9). Like our patient, C stneptococci in man. Am J Med 1979;&450-7. this adolescent male had recurrent episodes of sore Stamm A, Cobbs D. Group C streptococcal pneumonia: Rethroat. Culture showed Group C beta hemolytic port of a fatal case and review of literature. Rev Infect Dis 1980;2l&39-98. Streptococcus. Partial resohrtion of symptoms with 5. Benjamin J, Pekeilo V. Pharyngitis due to oral penicilbn .was noted, but symptoms recurred C hemolytic streptococci in children.J Pediatr 1976;89 with the discontinuation of therapy. Tonsillectomy 6. Kirby W, Rants L. Streptococcic bacteria c;red with sulfadiwas perfcmned, Gyoup C Streptococcus was isolated azine. Arch Intern Med 1943;71:620-9. tonsils, and the patient had no re7. Kiss F, +astnne C. The role of the mucoid polysacharide year of follow-up. (hyaluronic acid) in the virulence of group A hemolytic strep tococci. J Exp Med lm79.3194. Beta hemo@tic Streptococcus C disease is a rare 8. Schwartz R, Kneer R. Nermnses K. Acute epiglottitis caused CRUST,however, of endocarditis B, bacteremia, and by Ehemoljrtic g&up C streptococci. 6 J Dis Child ~&is. A milk-borne outbreak of pharyngitis with 1982;136:558-9. ~ymphachitis was described by Duca et al. (II). 9. W$ni~ V, Ely J, Ryan K.Recurrent group C streptococcal Group C Streptococcus was isolated from the throat tonsillitis in an adolescent male q&g tonsillectomy. m Pediatr 1980;19:829-39. of 85 pat+Ms. Approximately one third of the affected patien:s 10. Ramaswam G, Ambrose N, Locldand S, et al. Sfrept~ loped renal involvement during equisimilis ( Gy r01.1~ C) as z cause of ophthalmic tion. the second or week of illness. The diagnosis Sot Clin Path01i981;79:365-6. of acute @omtionephritis was confirmed by renal 11. Duca E, Radu C, Vita A. A new nephritogenic streptococcus. biopsy, volhard’s criteria, and filtered fraction data. J Hyg 1%9;67z691-4.
Generally considered a wo Group C Streptococcus can be
Group C Streptococcus. I tqcoccus is asymptoomatic. 14-year-old fernale who had beta hemolytic Streptococcus
orrae, Croup C Strepis is a case report of a repeated episodes of Group C pharyngitis.
Case Report A M-year-old Taxmer Stage 5 white female was in good health until she developed a sore throat and difficulty in swallowing of several days duraticm. Physical examination revealed a sick-looking atebrile adolescent with exudative
a 36hour hospitalization. ese symptoms were accomnction tests. Blood cultures panied by elevated liver were sterile, and viral hep s screen as well as titers for cytomegalovirus (CMV), and Epstein43arr (EBV) virus were negative. Over the next 3 months, the patient experienced exacerbations of tonsillopharyngitis. Throat cultures consistently grew Group C beta hemolytic Streptococci sensitive to penicillin and ampicillin. An ASQ titer taken at least t-&e times had been evaluated. In ite of treatment regand oral ampicillin, imens of intramuscular bicillin 1-2 500 mg four times daily for 10 days, the symptoms
persisted.
From the Division of Adolescent Medicine, Dqxartmentof Pediatrics, Idniversity of California San Diego School of Medicine and Medical Center. Address reprint requests to: Maria C. Mwgan, M.D., Division of Adolescent Medicine H 814-F, University ofGl@ornia San Diego Medical Center, 225 Dickinson St., San Diego, CA 92103. hktuscript accepted December 15,1988. Q sodety for Adolescent Medicine. 1989
Further history revealed that the patient had been ing with her pet cat. me patient had a tonsffectomy 6 months later. TOnSiE tissue was sent for aerobic and anaerobic cultures negative for ail organisms inclu month after surgery, a repeat throat culture was still neg421
422
MORGAN AND RICE
ative for beta hemolytic Streptocoscus. The patient has been asymptomatic for over 1 year.
Some key clinical issues conce streptococcus infections are: 1. leukocytosis is tim
Discussion ~&UPC S~~~@~CUCCU~ has been implicated as the
16,
2.
present (3); our patient cause of wound infection, postpartum infection, tom ~ill~pharyngitis, pneumonia, urinary tract infection, osteomyelitis, septicemia, meningitis (X,2), and endocarditis (3). There are four species of Group C Streptococcus: Equisimilis, Str~~cus zouepidemi- 3. dw, Streptwccus qui, and Streptococcus dysgdacth?. Ihe four species are differentiated by their biochemreported. ical properties, host, and pathogenic@ in humans (4) Styqt~s quisimdis is often referred to as the human Streptococcu> C (ti) and is the most comTreatment and ~r~e~tion monly implicated etioiogk agent in humans in idenThe antibiotic of tified Strep C infections. Among the four species, S. penicillin allergy quisidis is the only one that produces streptokichloramphenicol nase and streptolysin 0 (6) The streptokinase prowound infection duced may contribute to its pathogenicity and prevent local and metastic suppura increased virulence (6,7). Animals are a major rescations. ervoir of S. quisimilis Group C Streptococcus and it has been isolated in the pharynx of healthy domestic The authors are grateful to Wayne Danker, M.D., foFMs animals (4). We speculate that our patient’s pet cat advice concerning this patient, to Marianne Felice, M.D., may have been the reservoir for reinfection. editorial comments, and to Dottie McGlone for her manuscript Childhood exanthems such as varicella have been preparation. associated with Streptococcal illness. Swartz et al. reported a case of Streptococcus C epiglottitis in a eferences 9-year-old child with chickenpox (8). The presence of Group C Streptococcus was confirmed by blood 1. Chung S. Meningitis caused by Streptococcus quisimilis. J Uin Path01 1982;79:769. and epiglottis cultures. Noble J, McGowan K. Group C Streptococcal pneumonia in Our patient’s history closely parallelQthat of a ISan adolescenk. Am J Dis Child 1983;137:1023. year-old male with recurrent Group C Stqtococcal Mohr D, Feist D, Washington J, et al. onsduetogroup tonsillitis reported by Fulginitti (9). Like our patient, C stneptococci in man. Am J Med 1979;&450-7. this adolescent male had recurrent episodes of sore Stamm A, Cobbs D. Group C streptococcal pneumonia: Rethroat. Culture showed Group C beta hemolytic port of a fatal case and review of literature. Rev Infect Dis 1980;2l&39-98. Streptococcus. Partial resohrtion of symptoms with 5. Benjamin J, Pekeilo V. Pharyngitis due to oral penicilbn .was noted, but symptoms recurred C hemolytic streptococci in children.J Pediatr 1976;89 with the discontinuation of therapy. Tonsillectomy 6. Kirby W, Rants L. Streptococcic bacteria c;red with sulfadiwas perfcmned, Gyoup C Streptococcus was isolated azine. Arch Intern Med 1943;71:620-9. tonsils, and the patient had no re7. Kiss F, +astnne C. The role of the mucoid polysacharide year of follow-up. (hyaluronic acid) in the virulence of group A hemolytic strep tococci. J Exp Med lm79.3194. Beta hemo@tic Streptococcus C disease is a rare 8. Schwartz R, Kneer R. Nermnses K. Acute epiglottitis caused CRUST,however, of endocarditis B, bacteremia, and by Ehemoljrtic g&up C streptococci. 6 J Dis Child ~&is. A milk-borne outbreak of pharyngitis with 1982;136:558-9. ~ymphachitis was described by Duca et al. (II). 9. W$ni~ V, Ely J, Ryan K.Recurrent group C streptococcal Group C Streptococcus was isolated from the throat tonsillitis in an adolescent male q&g tonsillectomy. m Pediatr 1980;19:829-39. of 85 pat+Ms. Approximately one third of the affected patien:s 10. Ramaswam G, Ambrose N, Locldand S, et al. Sfrept~ loped renal involvement during equisimilis ( Gy r01.1~ C) as z cause of ophthalmic tion. the second or week of illness. The diagnosis Sot Clin Path01i981;79:365-6. of acute @omtionephritis was confirmed by renal 11. Duca E, Radu C, Vita A. A new nephritogenic streptococcus. biopsy, volhard’s criteria, and filtered fraction data. J Hyg 1%9;67z691-4.