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Meningitis Caused by Streptococcus pyogenes in an Intravenous Drug User
276
Letters to the Editor
Most rashes were petechial or purpuric or a combination of both. The number of possible cases seen increased year on yearÐthere were 4, 15 and 21 cases of non-blanching rash and fever in the 1st, 2nd and 3rd years, of which there were respectively 1, 4 and 6 cases of proven meningococcal disease. Whether that is due to an increased awareness of detection (general practitioners or general public) or a genuine increase in incidence is unknown. In terms of morbidity, 11 children were admitted to the high dependency unit, of which four were transferred to the regional intensive care unit. The total number of children with any serious morbidity (i.e. shock, meningitis) was 12 (30%). The median hospital stay was 4 days (range 1±13). Rifampicin was given to the child and the immediate contacts as soon as a working diagnosis of meningococcal disease was made (without waiting for bacteriological confirmation). In all cases either a registrar or a paediatric consultant made the diagnosis. Rifampicin was given to 15 probable cases (11 confirmed and four suspected). Fourteen of the 15 cases were notified to the Consultant in Communicable Disease Control (CCDC). Prophylaxis to those beyond the immediate family were all dealt with by the CCDC. In our retrospective review, 15 out of 40 (37.5%) children with fever and petechiae had strong clinical evidence of meningococcal disease (probable disease). The rest had alternative diagnoses that were unlikely to be of meningococcal aetiology (possible cases). Fever and petechiae often prompt clinicians to start prophylaxis in all contacts. We reserved our prophylaxis for those in contact with a probable case. This was further in discussion with the CCDC. To ensure appropriate prophylaxis of close contacts, petechial rash and fever in a child needs to be differentiated into probable and possible meningococcal disease by clinicians and CCDCs.
Indraneel Banerjee1, Richard Roberts2 and Nick Looker3 1 Department of Child Health, University Hospital of Wales, Cardiff CF14 4XW, UK; 2 North Wales Health Authority, Preswylfa, Hendy Road, Mold CH71PZ, UK; 3 Glan Clwyd Hospital, Bodelwyddan LL18 5UJ, UK
References 1 Palmer SR, Corson, J, Hall R, Payne S, Ludlow J, Deere B, Jones H, Kaul S, Stubbins J, Williams R, Walapu M, Spence A, Jenkins P, Donald D. Meningococcal disease in Wales: clinical features, outcome and public health management. J Infect 1992; 25: 321±328. 2 Stuart JM, Monk PN, Lewis DA, Constantine C, et al. Management of clusters of meningococcal disease. Commun Dis Rep CDR Rev 1997; 7: R3±R5. 3 Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr 1997; 131(3): 398±404. 4 Van Nguyen Q, Nguyen EA, Weiner LB. Incidence of invasive bacterial disease in children with fever and petechiae. Pediatrics 1984; 74(1): 77±80.
doi:10.1053/jinf.2002.0975, available online at http://www.idealibrary.com on
Meningitis Caused by Streptococcus pyogenes in an Intravenous Drug User Sir, Streptococcal meningitis is an uncommon condition most often occurring in relation to neurosurgery or brain abscesses [1]. We report a patient with a history of injecting drug use who presented with neck stiffness and was found to have Streptococcus pyogenes meningitis. We believe this is the first report of a previously well patient presenting with streptococcal meningitis in the context of injecting drug use. A 24-year-old unemployed man with a 2-year history of intravenous heroin use was admitted with a 4-day history of frontal headache, photophobia, vomiting and fever. He was unwell, distressed, pale, sweaty and dehydrated with a temperature of 38.5 C. Pulse was 88, blood pressure 104/60. Examination of the chest and auscultation of the heart revealed no abnormal signs. His Glasgow coma score was 15/15 but there was demonstrable neck stiffness and photophobia. There were no focal neurological signs and no papilloedema on fundoscopy. Auroscopic examination was normal and there was no evidence of cellulitis. Initial investigations showed normal electrolytes, urea of 9.8 mmol/l, Hb 118 g/l, WCC 6.7109 lÿ1, platelets 128109 lÿ1 and CRP 192 mg/l. Coagulation screen and chest X-ray were normal. He was treated immediately with intravenous fluids and intravenous Cefotaxime. A lumbar puncture was attempted but failed. Twelve hours after admission a petechial rash appeared on the feet. A lumbar puncture was again attempted and on this occasion yielded cloudy cerebrospinal fluid. Microscopy revealed no red blood cells, 1500 white cells/microlitre, 90% of which were polymorphs, and no organisms on gram stain. The protein content was 1.52 g/l and glucose 2.5 mmol/l (blood glucose of 5.9 mmol/l). There was no growth on culture. Cytology examination of cerebrospinal fluid showed appearances in keeping with acute bacterial meningitis. Treatment was continued with high dose Cefotaxime 4 g t.d.s plus 4 mg Dexamethasone t.d.s. Blood cultures from admission grew Streptococcus pyogenes of Lancefield Group A on day 2. An echocardiogram showed no evidence of endocarditis. The patient was treated with a 7 day course of intravenous antibiotics and made a full recovery with no neurological sequelae. Streptococcal meningitis has not previously been described in injecting drug users. In one study which included 29 cases of streptococcal meningitis, it was shown that 28/29 of these patients had undergone neurosurgery or trauma or had a known source of infection [1]. In another group of nine patients with group A beta-haemolytic streptococcal meningitis, six had underlying neurosurgical conditions and five had upper respiratory tract infections [2]. Our patient had none of these risk factors. The incidence of streptococcal bacteraemia in the population has been shown to be rising, and this has been attributed to the increase in injecting drug use [3]. However, of 127 episodes of Streptococcus pyogenes bacteraemia over 27 years in a mixed group of patients,
Letters to the Editor meningitis was not reported feature in any patient [4]. In 80% of these patients there was an identified focus, with almost half of these being cellulitis. In another population of 40 patients with streptococcal bacteraemia, all of whom were intravenous drug users there were no patients with meningitis [5]. Streptococcus pyogenes meningitis is the commonest in neonates but can also occur in older children [6] in whom neurological sequelae are commoner [7]. Whilst meningism without cerebrospinal fluid abnormality is a recognised feature of bacteraemia, in this case the patient clearly had bacterial meningitis. The absence of any isolate from the CSF is probably a result of the patient having received 24 h of antibiotic treatment, though the blood cultures were obtained before starting antibiotics. A petechial rash has not previously been described in Streptococcus pyogenes infection, but has been reported in association with neonatal group B streptococcal meningitis [8]. The patient's normal clotting screen did not support disseminated intravascular coagulation as a cause of the rash. We postulate that streptococcal bacteraemia secondary to injection drug use resulted in this patient's meningitis, and suggest that streptococcal meningitis is another infection which may be associated with injection drug use.
D. Robson*, A.M. Cadwgan and R.B.S. Laing The Infection Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
277
*Corresponding author. Tel.: 01224 553705; Fax: 01224 559227; E-mail address: [email protected] (D. Robson)
References 1 Cabellos C, Viladrich PF, Corredoira J, Verdaguer R, Ariza J, Gudiol F. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999; 28(5): 1104±1108. 2 Sommer R, Rohner P, Garbino J, et al. Group A beta-haemolytic streptococcus meningitis: clinical and microbiological features of nine cases. Clin Infect Dis 1999; 29(4): 929±931. 3 Lentnek AL, Giger O, O'Rourke E. Group A beta-haemolytic streptococcal bacteraemia and intravenous substance abuse. A growing clinical problem? Archiv Int Med 1990; 150(1): 89±93. 4 Breathnach AS, Eykyn SJ. Streptococcus pyogenes bacteraemia: a 27year study in a London teaching hospital. Scand J Infect Dis 1997; 29(5): 473±478. 5 Barg NL, Kish MA, Kauffman CA, Supena RB. Group A streptococcal bacteraemia in intravenous drug abusers. Amer J Med 1985; 78(4): 569±574. 6 Berner R, Herdeg S, Gordjani N, Brandis M. Streptococcus pyogenes meningitis: report of a case and review of the literature. Eur J Pediatr 2000; 159(7): 527±529. 7 Baraldes MA, Domingo P, Mauri A, et al. Group A streptococcal meningitis in the antibiotic era. Eur J Clin Microbiol Infect Dis 1999; 18(8): 572±582. 8 Lynn NJ, Pauly TH, Desai NS. Purpura fulminans in three cases of early onset neonatal group B streptococcal meningitis. J Perinatol 1991; 11: 144±146.
Letters to the Editor
Most rashes were petechial or purpuric or a combination of both. The number of possible cases seen increased year on yearÐthere were 4, 15 and 21 cases of non-blanching rash and fever in the 1st, 2nd and 3rd years, of which there were respectively 1, 4 and 6 cases of proven meningococcal disease. Whether that is due to an increased awareness of detection (general practitioners or general public) or a genuine increase in incidence is unknown. In terms of morbidity, 11 children were admitted to the high dependency unit, of which four were transferred to the regional intensive care unit. The total number of children with any serious morbidity (i.e. shock, meningitis) was 12 (30%). The median hospital stay was 4 days (range 1±13). Rifampicin was given to the child and the immediate contacts as soon as a working diagnosis of meningococcal disease was made (without waiting for bacteriological confirmation). In all cases either a registrar or a paediatric consultant made the diagnosis. Rifampicin was given to 15 probable cases (11 confirmed and four suspected). Fourteen of the 15 cases were notified to the Consultant in Communicable Disease Control (CCDC). Prophylaxis to those beyond the immediate family were all dealt with by the CCDC. In our retrospective review, 15 out of 40 (37.5%) children with fever and petechiae had strong clinical evidence of meningococcal disease (probable disease). The rest had alternative diagnoses that were unlikely to be of meningococcal aetiology (possible cases). Fever and petechiae often prompt clinicians to start prophylaxis in all contacts. We reserved our prophylaxis for those in contact with a probable case. This was further in discussion with the CCDC. To ensure appropriate prophylaxis of close contacts, petechial rash and fever in a child needs to be differentiated into probable and possible meningococcal disease by clinicians and CCDCs.
Indraneel Banerjee1, Richard Roberts2 and Nick Looker3 1 Department of Child Health, University Hospital of Wales, Cardiff CF14 4XW, UK; 2 North Wales Health Authority, Preswylfa, Hendy Road, Mold CH71PZ, UK; 3 Glan Clwyd Hospital, Bodelwyddan LL18 5UJ, UK
References 1 Palmer SR, Corson, J, Hall R, Payne S, Ludlow J, Deere B, Jones H, Kaul S, Stubbins J, Williams R, Walapu M, Spence A, Jenkins P, Donald D. Meningococcal disease in Wales: clinical features, outcome and public health management. J Infect 1992; 25: 321±328. 2 Stuart JM, Monk PN, Lewis DA, Constantine C, et al. Management of clusters of meningococcal disease. Commun Dis Rep CDR Rev 1997; 7: R3±R5. 3 Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr 1997; 131(3): 398±404. 4 Van Nguyen Q, Nguyen EA, Weiner LB. Incidence of invasive bacterial disease in children with fever and petechiae. Pediatrics 1984; 74(1): 77±80.
doi:10.1053/jinf.2002.0975, available online at http://www.idealibrary.com on
Meningitis Caused by Streptococcus pyogenes in an Intravenous Drug User Sir, Streptococcal meningitis is an uncommon condition most often occurring in relation to neurosurgery or brain abscesses [1]. We report a patient with a history of injecting drug use who presented with neck stiffness and was found to have Streptococcus pyogenes meningitis. We believe this is the first report of a previously well patient presenting with streptococcal meningitis in the context of injecting drug use. A 24-year-old unemployed man with a 2-year history of intravenous heroin use was admitted with a 4-day history of frontal headache, photophobia, vomiting and fever. He was unwell, distressed, pale, sweaty and dehydrated with a temperature of 38.5 C. Pulse was 88, blood pressure 104/60. Examination of the chest and auscultation of the heart revealed no abnormal signs. His Glasgow coma score was 15/15 but there was demonstrable neck stiffness and photophobia. There were no focal neurological signs and no papilloedema on fundoscopy. Auroscopic examination was normal and there was no evidence of cellulitis. Initial investigations showed normal electrolytes, urea of 9.8 mmol/l, Hb 118 g/l, WCC 6.7109 lÿ1, platelets 128109 lÿ1 and CRP 192 mg/l. Coagulation screen and chest X-ray were normal. He was treated immediately with intravenous fluids and intravenous Cefotaxime. A lumbar puncture was attempted but failed. Twelve hours after admission a petechial rash appeared on the feet. A lumbar puncture was again attempted and on this occasion yielded cloudy cerebrospinal fluid. Microscopy revealed no red blood cells, 1500 white cells/microlitre, 90% of which were polymorphs, and no organisms on gram stain. The protein content was 1.52 g/l and glucose 2.5 mmol/l (blood glucose of 5.9 mmol/l). There was no growth on culture. Cytology examination of cerebrospinal fluid showed appearances in keeping with acute bacterial meningitis. Treatment was continued with high dose Cefotaxime 4 g t.d.s plus 4 mg Dexamethasone t.d.s. Blood cultures from admission grew Streptococcus pyogenes of Lancefield Group A on day 2. An echocardiogram showed no evidence of endocarditis. The patient was treated with a 7 day course of intravenous antibiotics and made a full recovery with no neurological sequelae. Streptococcal meningitis has not previously been described in injecting drug users. In one study which included 29 cases of streptococcal meningitis, it was shown that 28/29 of these patients had undergone neurosurgery or trauma or had a known source of infection [1]. In another group of nine patients with group A beta-haemolytic streptococcal meningitis, six had underlying neurosurgical conditions and five had upper respiratory tract infections [2]. Our patient had none of these risk factors. The incidence of streptococcal bacteraemia in the population has been shown to be rising, and this has been attributed to the increase in injecting drug use [3]. However, of 127 episodes of Streptococcus pyogenes bacteraemia over 27 years in a mixed group of patients,
Letters to the Editor meningitis was not reported feature in any patient [4]. In 80% of these patients there was an identified focus, with almost half of these being cellulitis. In another population of 40 patients with streptococcal bacteraemia, all of whom were intravenous drug users there were no patients with meningitis [5]. Streptococcus pyogenes meningitis is the commonest in neonates but can also occur in older children [6] in whom neurological sequelae are commoner [7]. Whilst meningism without cerebrospinal fluid abnormality is a recognised feature of bacteraemia, in this case the patient clearly had bacterial meningitis. The absence of any isolate from the CSF is probably a result of the patient having received 24 h of antibiotic treatment, though the blood cultures were obtained before starting antibiotics. A petechial rash has not previously been described in Streptococcus pyogenes infection, but has been reported in association with neonatal group B streptococcal meningitis [8]. The patient's normal clotting screen did not support disseminated intravascular coagulation as a cause of the rash. We postulate that streptococcal bacteraemia secondary to injection drug use resulted in this patient's meningitis, and suggest that streptococcal meningitis is another infection which may be associated with injection drug use.
D. Robson*, A.M. Cadwgan and R.B.S. Laing The Infection Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
277
*Corresponding author. Tel.: 01224 553705; Fax: 01224 559227; E-mail address: [email protected] (D. Robson)
References 1 Cabellos C, Viladrich PF, Corredoira J, Verdaguer R, Ariza J, Gudiol F. Streptococcal meningitis in adult patients: current epidemiology and clinical spectrum. Clin Infect Dis 1999; 28(5): 1104±1108. 2 Sommer R, Rohner P, Garbino J, et al. Group A beta-haemolytic streptococcus meningitis: clinical and microbiological features of nine cases. Clin Infect Dis 1999; 29(4): 929±931. 3 Lentnek AL, Giger O, O'Rourke E. Group A beta-haemolytic streptococcal bacteraemia and intravenous substance abuse. A growing clinical problem? Archiv Int Med 1990; 150(1): 89±93. 4 Breathnach AS, Eykyn SJ. Streptococcus pyogenes bacteraemia: a 27year study in a London teaching hospital. Scand J Infect Dis 1997; 29(5): 473±478. 5 Barg NL, Kish MA, Kauffman CA, Supena RB. Group A streptococcal bacteraemia in intravenous drug abusers. Amer J Med 1985; 78(4): 569±574. 6 Berner R, Herdeg S, Gordjani N, Brandis M. Streptococcus pyogenes meningitis: report of a case and review of the literature. Eur J Pediatr 2000; 159(7): 527±529. 7 Baraldes MA, Domingo P, Mauri A, et al. Group A streptococcal meningitis in the antibiotic era. Eur J Clin Microbiol Infect Dis 1999; 18(8): 572±582. 8 Lynn NJ, Pauly TH, Desai NS. Purpura fulminans in three cases of early onset neonatal group B streptococcal meningitis. J Perinatol 1991; 11: 144±146.