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Group C streptococcal sinusitis
reuzumc
u6o~aryagology.~ rrancaples ana m-acme
Am J Otolaryngol 11:352-354,
1990
Group C Streptococcal PATRICK
G. GALLAGHER,
MD,*
CHARLES
M. MYER
III, MD,
Sinusitis KERRY CRONE, MD, AND
GEORGEBENZING III, MD
The group C streptococci have emerged as important human pathogens. A case of group C streptococcal sinusitis in a 6-year-old girl is reported and four cases of group C streptococcal sinusitis are reviewed. Age less than 18 years, central nervous system complications, and a delay in the institution of adequate therapy were features common to all five cases. Three patients were bacteremic with group C streptococci and two patients died. These cases suggest that when beta-hemolytic streptococci are isolated from sinus culture, serogrouping should be performed. When group C streptococci are identified, appropriate antimicrobial therapy should be instituted and one should be alert for suppurative intracranial complications. AM J OTOLARYNGOL 11:352-354. 0 1990 by W.B. Saunders Company.
The
role
pathogens, been
of group
C streptococci
particularly
in pediatric
described
in recent
C streptococcal significant
reports.l”
infections
morbidity
group C streptococcal is described,
and four cases in pediatric
sinusitis
The
purpose
importance
of this of group
and to discuss group
mortality.
sinusitis
cal
of group patients
report
infections,
group with of girl
C streptococare reviewed.
is to emphasize
C streptococci
has
A case
in a 6-year-old
the appropriate
C streptococcal
Serious
may be associated
and
nasal sinuses. No bony or intracerebral abnormalities were seen. Intravenous cefuroxime (225 mg/kg/d in divided doses every 8 hours) was administered and a left frontoethmoidectomy, antral irrigation, and nasoantral window were performed. Material obtained at surgery yielded B-hemolytic group C streptococcus, Streptococcus equisimilis [minimum inhibitory concentration SO.06 pg/mL, minimum bactericidal concentration CO.06 p,g/mL), and four or more anaerobic organisms. Blood culture yielded S equisimiiis. Within 48 hours, the patient was afebrile and clinically improved. She received intravenous cefuroxime for 6 days, and was discharged to continue oral amoxicillimclavulanic acid 50 mg/kg/d for 8 days. Four days later, she was readmitted febrile (36.2%) with recurrent fluctuant, nonerythematous swelling over the left frontal area. S equisimilis, Peptococcus asaccharolyticus, and B-lactamase producing Bacteroides intermedius were cultured from 30 mL of foul-smelling, purulent material obtained at surgical drainage. The abscess site healed rapidly, and the patient was discharged after 7 days of intravenous cephalothin 170 mglkgld, with instructions to continue oral cephalexin 55 mg/kg/d for 7 days. Six days later, she was admitted with a history of headache, fever, lethargy, and anorexia. On examination, she was lethargic and exhibited bilateral papilledema and recurrent fluctuant swelling in the left frontal area. Left maxillary sinus opacification and a radiolucent skull defect of the left frontal bone were observed on radiographs. A left frontal lobe brain abscess was seen on computed tomography (Fig 1). The frontal abscess was aspirated, and a left external ethmoidectomy with left antral irrigation and nasoantral window were performed. Intravenous penicillin (300,000 pm/kg/d) and chloramphenicol (80 mg/kg/d) were administered. The aspirate grew S equisimilis, B intermedius, Bacteroides ureolyticus, and Peptostreptococcus nucros. The abscess required reaspiration and then excision, 10 and 13 days later, respectively. Because chloramphenico1 could not be detected in the excised abscess, metronidazole was substituted and continued with penicillin for 3 weeks, for a total of 6 weeks of intravenous antibiotic therapy. At follow up 1 year later, the patient had no neurologic sequelae. Evolving areas of enceph-
as human patients,
the
as pathogens
therapy
of serious
particularly
si-
nusitis.
CASE REPORT A 6-year-old girl was admitted to Children’s Hospital Medical Center with a 2 week history of nasal congestion and a 36-hour history of fever, headache, and left forehead swelling. On examination, her temperature was 38.3%. She had purulent nasal discharge and tender, boggy edema in the left frontal area extending to the zygoma. Opacification of the left maxillary, ethmoid, and frontal sinuses was noted on sinus radiographs. Left maxillary, ethmoid, and frontal opacification and soft tissue swelling, extending from the preseptal region of the left orbit over the left forehead, were noted on computed tomography of the head and para-
Received January 10, 1990, from the Children’s Hospital Medical Center and the Departments of Pediatrics, Otolaryngology and Maxillofacial Surgery, and Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH. Accepted for publication February 29, 1990. *Present address: Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. Address correspondence and reprint requests to Charles M. Myer III, MD, Department of Otolaryngology and Maxillofacial Surgery, Children’s Hospital Medical Center, Cincinnati, OH 45229-2899. 0 1990 by W.B. Saunders Company. 0196-0709/90/1105-0005$5.0010
352
353
GALLAGHER ET AL
Figure 1. A large frontal brain abscess with marked mass effect is noted on computed tomography.
alomalacia in the region of the previous observed on computed tomography.
abscess
were
DISCUSSION
The group C streptococci, which includes S equisimilis, Streptococcus equi, Streptococcus zooepidemicus, Streptococcus dysgalactiae, and Streptococcus anginosus, have emerged as significant human pathogens. Approximately one quarter of reported cases of group C streptococcal infection have occurred in pediatric patients.lr’ Serious infections caused by these organisms, including meningitis, endocarditis, pneumonia, bacteremia, septic arthritis, and osteomyelitis, have been described. Significant morbidity and a mortality rate of approximately 20% have been associated with group C streptococcal infection.’ Group C streptococci colonize the nasopharnyx, umbilicus, skin, and genitourinary tract. Asymptomatic pharyngeal carriage rates range from 1.4% to 39L3.* Upper respiratory infections due to group C streptococci include pharyngitis, sinusitis, tonsillitis, and epiglottitis.‘82,5,6 Group C streptococcal sinusitis is uncommon. In one study of 50 pediatric patients with acute sinusitis, 79
TABLE 1.
Patients
With
CASE No.
AGE (YR)
SEX
BACTEREMIA
1
13 17 10
M M F M
+ _ _ +
F
+
2 3 4 5
15
6
maxillary sinus aspirates were obtained; only one culture yielded group C streptococci.7 The significance of group C streptococci in human infections mandates its proper identification. Many clinical laboratories only identify P-hemolytic streptococci as bacitracin-susceptible or bacitracin-resistant. This may lead to confusion of group C streptococci with group A streptococci. Whenever bacitracin-susceptible P-hemolytic streptococci are isolated from a normally sterile site, eg blood, cerebrospinal fluid, joint fluid, lung or sinus, serogrouping, to identify the offending organism, should be performed. Group C streptococci are susceptible in vitro to penicillin, cephalosporins, clindamycin, chloramphenicol, and erythromycin.8,g In vitro synergy has been demonstrated against group C streptococci with combinations of penicillin and gentamicin.l’*ll Intravenous penicillin appears to be the agent of choice in treating group C streptococcal infection.‘,’ Penicillin plus an aminoglycoside may be a superior regimen, but there are insufficient data to recommend this combination. The optimal route and duration for antimicrobial therapy of group C streptococcal infection are unknown. In our case and in case four of Table 1,
Group C Streptococcal
Sinusitis
COMPLICATIONS Meningitis, subdural Meningitis Orbital abscess
empyema
Epidural abscess, frontal bone osteomyelitis Brain abscess, frontal bone osteomyelitis
OUTCOME
REFERENCE
Lived
7 2 2 1
Lived
This report
Died Died Lived
GROUP C STREPTOCOCCAL
354
treatment of group C streptococcal acute sinusitis and bacteremia with short courses of parenteral antibiotics (6 and 4 days, respectively) followed by oral antibiotic therapy may have contributed to the development of central nervous system complications. Slow response to antimicrobial therapy has been noted in cases of group C streptococcal infection.‘92*8 In some patients, this slow response has been attributed to penicillin tolerance (a minimum inhibitory concentration to minimum bactericidal concentration ratio of 32 or greater).*’ It has been recommended that both the minimum inhibitory concentration and minimum bactericidal concentration of penicillin for group C streptococci be determined in serious infections, and that the use of gentamicin in addition to penicillin be considered, pending susceptibility testing.” However, the clinical significance of penicillin tolerance in @hemolytic streptococci is unclear and data to make specific recommendations are 1acking.l’ Penicillin tolerance was not found in our case of group C streptococcal sinusitis. The detailed reports of group C streptococcal sinusitis in Table 1 are remarkable for a pediatric predominance and a high rate of central nervous system complications. This finding may be attributed to inadequate medical and/or surgical therapy in all five cases. Delay in diagnosis, delay in the initiation of appropriate medical or surgical therapy, and the use of improper antimicrobial agents were noted. For example, cases three and five were initially treated with a cephalosporin alone; an inadequate therapy for sinusitis, particularly when complicated by anaerobic organisms. The virulence of group C streptococci and penicillin tolerance may also have contributed to the high rate of central nervous system complications. Although bacteremia is uncommon in patients with sinusitis, it was present in three of five cases of group C streptococcal sinusitis. Findings in these five cases of sinusitis suggest that when R-hemolytic streptococci are isolated
SINUSITIS
from sinus culture, serogrouping should be performed. When group C streptococci are isolated from sinus culture, appropriate parenteral antimicrobial therapy should be initiated without delay. In addition, one should be alert for suppurative intracranial complications. When intracranial abscesses complicate sinusitis, surgical drainage of loculated infection should be employed in addition to antimicrobial therapy.13 We feel that surgical therapy contributed to the recovery of our patient, who, to our knowledge, is the first reported survivor of a group C streptococcal brain abscess. References 1. Salata RA, Lerner PI, Shlaes DM, et al: Infections due to Lancefield group C streptococci. Medicine 1989; 68:225-239 2. Arditi M. Shulman ST. Davis AT. et al: Groun C betahemolytic streptococcal infections in children: Nine-pediatric cases and review. Rev Infect Dis 1989; 11:34-45 3. Hoffmann S: The throat carrier rate of group A and other beta hemolytic streptococci among patients in general practice. Acta Path01 Microbial Immunol Stand (B) 1985; 93:347351 4. Hare R: Sources of haemolytic streptococcal infection of wounds in war and in civil life. Lancet 1940; 238:109-112 5. Schwartz RH, Knerr RJ, Hermansen K, et al: Acute epiglottitis caused by beta-hemolytic group C streptococci. Am J Dis Child 1982; 136:558-559 6. Wald ER, Reilly JS, Casselbrant M, et al: Treatment of acute maxillary sinusitis in childhood: A comparative study of amoxicillin and cefaclor. J Pediatr 1984; 104:297-302 7. Layon J, McCulley D: Subdural empyema and group C streptococcus. South Med J 1985; 78:64-66 8. Mohr DN, Feist DJ, Washington JA, II, et al: Infections due to group C streptococci in man. Am J Med 1979; 66:450-456 9. Rolston KVI, LeFrock JL, Schell RF: Activity of nine antimicrobial agents against Lancefield group C and group G streptococci. Antimicrob Agents Chemother 1982; 22:930-932 10. Portnoy D, Prentis J, Richards GK: Penicillin tolerance of human isolates of group C streptococci. Antimicrob Agents Chemother 1981; 20:235-238 11. Rolston KVI, Chandrasekar PH, LeFrock JL: Antimicrobial tolerance in group C and group G streptococci. J Antimicrab Chemother 1984; 13:389-392 12. Woolfrey BF: Penicillin tolerance in beta-streptococci. Stand J Infect Dis 1988; 20:235-236 13. Johnson DL, Markle BM, Wiedermann BL, et al: Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr 1988; 113:15-23
u6o~aryagology.~ rrancaples ana m-acme
Am J Otolaryngol 11:352-354,
1990
Group C Streptococcal PATRICK
G. GALLAGHER,
MD,*
CHARLES
M. MYER
III, MD,
Sinusitis KERRY CRONE, MD, AND
GEORGEBENZING III, MD
The group C streptococci have emerged as important human pathogens. A case of group C streptococcal sinusitis in a 6-year-old girl is reported and four cases of group C streptococcal sinusitis are reviewed. Age less than 18 years, central nervous system complications, and a delay in the institution of adequate therapy were features common to all five cases. Three patients were bacteremic with group C streptococci and two patients died. These cases suggest that when beta-hemolytic streptococci are isolated from sinus culture, serogrouping should be performed. When group C streptococci are identified, appropriate antimicrobial therapy should be instituted and one should be alert for suppurative intracranial complications. AM J OTOLARYNGOL 11:352-354. 0 1990 by W.B. Saunders Company.
The
role
pathogens, been
of group
C streptococci
particularly
in pediatric
described
in recent
C streptococcal significant
reports.l”
infections
morbidity
group C streptococcal is described,
and four cases in pediatric
sinusitis
The
purpose
importance
of this of group
and to discuss group
mortality.
sinusitis
cal
of group patients
report
infections,
group with of girl
C streptococare reviewed.
is to emphasize
C streptococci
has
A case
in a 6-year-old
the appropriate
C streptococcal
Serious
may be associated
and
nasal sinuses. No bony or intracerebral abnormalities were seen. Intravenous cefuroxime (225 mg/kg/d in divided doses every 8 hours) was administered and a left frontoethmoidectomy, antral irrigation, and nasoantral window were performed. Material obtained at surgery yielded B-hemolytic group C streptococcus, Streptococcus equisimilis [minimum inhibitory concentration SO.06 pg/mL, minimum bactericidal concentration CO.06 p,g/mL), and four or more anaerobic organisms. Blood culture yielded S equisimiiis. Within 48 hours, the patient was afebrile and clinically improved. She received intravenous cefuroxime for 6 days, and was discharged to continue oral amoxicillimclavulanic acid 50 mg/kg/d for 8 days. Four days later, she was readmitted febrile (36.2%) with recurrent fluctuant, nonerythematous swelling over the left frontal area. S equisimilis, Peptococcus asaccharolyticus, and B-lactamase producing Bacteroides intermedius were cultured from 30 mL of foul-smelling, purulent material obtained at surgical drainage. The abscess site healed rapidly, and the patient was discharged after 7 days of intravenous cephalothin 170 mglkgld, with instructions to continue oral cephalexin 55 mg/kg/d for 7 days. Six days later, she was admitted with a history of headache, fever, lethargy, and anorexia. On examination, she was lethargic and exhibited bilateral papilledema and recurrent fluctuant swelling in the left frontal area. Left maxillary sinus opacification and a radiolucent skull defect of the left frontal bone were observed on radiographs. A left frontal lobe brain abscess was seen on computed tomography (Fig 1). The frontal abscess was aspirated, and a left external ethmoidectomy with left antral irrigation and nasoantral window were performed. Intravenous penicillin (300,000 pm/kg/d) and chloramphenicol (80 mg/kg/d) were administered. The aspirate grew S equisimilis, B intermedius, Bacteroides ureolyticus, and Peptostreptococcus nucros. The abscess required reaspiration and then excision, 10 and 13 days later, respectively. Because chloramphenico1 could not be detected in the excised abscess, metronidazole was substituted and continued with penicillin for 3 weeks, for a total of 6 weeks of intravenous antibiotic therapy. At follow up 1 year later, the patient had no neurologic sequelae. Evolving areas of enceph-
as human patients,
the
as pathogens
therapy
of serious
particularly
si-
nusitis.
CASE REPORT A 6-year-old girl was admitted to Children’s Hospital Medical Center with a 2 week history of nasal congestion and a 36-hour history of fever, headache, and left forehead swelling. On examination, her temperature was 38.3%. She had purulent nasal discharge and tender, boggy edema in the left frontal area extending to the zygoma. Opacification of the left maxillary, ethmoid, and frontal sinuses was noted on sinus radiographs. Left maxillary, ethmoid, and frontal opacification and soft tissue swelling, extending from the preseptal region of the left orbit over the left forehead, were noted on computed tomography of the head and para-
Received January 10, 1990, from the Children’s Hospital Medical Center and the Departments of Pediatrics, Otolaryngology and Maxillofacial Surgery, and Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH. Accepted for publication February 29, 1990. *Present address: Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. Address correspondence and reprint requests to Charles M. Myer III, MD, Department of Otolaryngology and Maxillofacial Surgery, Children’s Hospital Medical Center, Cincinnati, OH 45229-2899. 0 1990 by W.B. Saunders Company. 0196-0709/90/1105-0005$5.0010
352
353
GALLAGHER ET AL
Figure 1. A large frontal brain abscess with marked mass effect is noted on computed tomography.
alomalacia in the region of the previous observed on computed tomography.
abscess
were
DISCUSSION
The group C streptococci, which includes S equisimilis, Streptococcus equi, Streptococcus zooepidemicus, Streptococcus dysgalactiae, and Streptococcus anginosus, have emerged as significant human pathogens. Approximately one quarter of reported cases of group C streptococcal infection have occurred in pediatric patients.lr’ Serious infections caused by these organisms, including meningitis, endocarditis, pneumonia, bacteremia, septic arthritis, and osteomyelitis, have been described. Significant morbidity and a mortality rate of approximately 20% have been associated with group C streptococcal infection.’ Group C streptococci colonize the nasopharnyx, umbilicus, skin, and genitourinary tract. Asymptomatic pharyngeal carriage rates range from 1.4% to 39L3.* Upper respiratory infections due to group C streptococci include pharyngitis, sinusitis, tonsillitis, and epiglottitis.‘82,5,6 Group C streptococcal sinusitis is uncommon. In one study of 50 pediatric patients with acute sinusitis, 79
TABLE 1.
Patients
With
CASE No.
AGE (YR)
SEX
BACTEREMIA
1
13 17 10
M M F M
+ _ _ +
F
+
2 3 4 5
15
6
maxillary sinus aspirates were obtained; only one culture yielded group C streptococci.7 The significance of group C streptococci in human infections mandates its proper identification. Many clinical laboratories only identify P-hemolytic streptococci as bacitracin-susceptible or bacitracin-resistant. This may lead to confusion of group C streptococci with group A streptococci. Whenever bacitracin-susceptible P-hemolytic streptococci are isolated from a normally sterile site, eg blood, cerebrospinal fluid, joint fluid, lung or sinus, serogrouping, to identify the offending organism, should be performed. Group C streptococci are susceptible in vitro to penicillin, cephalosporins, clindamycin, chloramphenicol, and erythromycin.8,g In vitro synergy has been demonstrated against group C streptococci with combinations of penicillin and gentamicin.l’*ll Intravenous penicillin appears to be the agent of choice in treating group C streptococcal infection.‘,’ Penicillin plus an aminoglycoside may be a superior regimen, but there are insufficient data to recommend this combination. The optimal route and duration for antimicrobial therapy of group C streptococcal infection are unknown. In our case and in case four of Table 1,
Group C Streptococcal
Sinusitis
COMPLICATIONS Meningitis, subdural Meningitis Orbital abscess
empyema
Epidural abscess, frontal bone osteomyelitis Brain abscess, frontal bone osteomyelitis
OUTCOME
REFERENCE
Lived
7 2 2 1
Lived
This report
Died Died Lived
GROUP C STREPTOCOCCAL
354
treatment of group C streptococcal acute sinusitis and bacteremia with short courses of parenteral antibiotics (6 and 4 days, respectively) followed by oral antibiotic therapy may have contributed to the development of central nervous system complications. Slow response to antimicrobial therapy has been noted in cases of group C streptococcal infection.‘92*8 In some patients, this slow response has been attributed to penicillin tolerance (a minimum inhibitory concentration to minimum bactericidal concentration ratio of 32 or greater).*’ It has been recommended that both the minimum inhibitory concentration and minimum bactericidal concentration of penicillin for group C streptococci be determined in serious infections, and that the use of gentamicin in addition to penicillin be considered, pending susceptibility testing.” However, the clinical significance of penicillin tolerance in @hemolytic streptococci is unclear and data to make specific recommendations are 1acking.l’ Penicillin tolerance was not found in our case of group C streptococcal sinusitis. The detailed reports of group C streptococcal sinusitis in Table 1 are remarkable for a pediatric predominance and a high rate of central nervous system complications. This finding may be attributed to inadequate medical and/or surgical therapy in all five cases. Delay in diagnosis, delay in the initiation of appropriate medical or surgical therapy, and the use of improper antimicrobial agents were noted. For example, cases three and five were initially treated with a cephalosporin alone; an inadequate therapy for sinusitis, particularly when complicated by anaerobic organisms. The virulence of group C streptococci and penicillin tolerance may also have contributed to the high rate of central nervous system complications. Although bacteremia is uncommon in patients with sinusitis, it was present in three of five cases of group C streptococcal sinusitis. Findings in these five cases of sinusitis suggest that when R-hemolytic streptococci are isolated
SINUSITIS
from sinus culture, serogrouping should be performed. When group C streptococci are isolated from sinus culture, appropriate parenteral antimicrobial therapy should be initiated without delay. In addition, one should be alert for suppurative intracranial complications. When intracranial abscesses complicate sinusitis, surgical drainage of loculated infection should be employed in addition to antimicrobial therapy.13 We feel that surgical therapy contributed to the recovery of our patient, who, to our knowledge, is the first reported survivor of a group C streptococcal brain abscess. References 1. Salata RA, Lerner PI, Shlaes DM, et al: Infections due to Lancefield group C streptococci. Medicine 1989; 68:225-239 2. Arditi M. Shulman ST. Davis AT. et al: Groun C betahemolytic streptococcal infections in children: Nine-pediatric cases and review. Rev Infect Dis 1989; 11:34-45 3. Hoffmann S: The throat carrier rate of group A and other beta hemolytic streptococci among patients in general practice. Acta Path01 Microbial Immunol Stand (B) 1985; 93:347351 4. Hare R: Sources of haemolytic streptococcal infection of wounds in war and in civil life. Lancet 1940; 238:109-112 5. Schwartz RH, Knerr RJ, Hermansen K, et al: Acute epiglottitis caused by beta-hemolytic group C streptococci. Am J Dis Child 1982; 136:558-559 6. Wald ER, Reilly JS, Casselbrant M, et al: Treatment of acute maxillary sinusitis in childhood: A comparative study of amoxicillin and cefaclor. J Pediatr 1984; 104:297-302 7. Layon J, McCulley D: Subdural empyema and group C streptococcus. South Med J 1985; 78:64-66 8. Mohr DN, Feist DJ, Washington JA, II, et al: Infections due to group C streptococci in man. Am J Med 1979; 66:450-456 9. Rolston KVI, LeFrock JL, Schell RF: Activity of nine antimicrobial agents against Lancefield group C and group G streptococci. Antimicrob Agents Chemother 1982; 22:930-932 10. Portnoy D, Prentis J, Richards GK: Penicillin tolerance of human isolates of group C streptococci. Antimicrob Agents Chemother 1981; 20:235-238 11. Rolston KVI, Chandrasekar PH, LeFrock JL: Antimicrobial tolerance in group C and group G streptococci. J Antimicrab Chemother 1984; 13:389-392 12. Woolfrey BF: Penicillin tolerance in beta-streptococci. Stand J Infect Dis 1988; 20:235-236 13. Johnson DL, Markle BM, Wiedermann BL, et al: Treatment of intracranial abscesses associated with sinusitis in children and adolescents. J Pediatr 1988; 113:15-23