January 1977 TheJournalofPEDIATRICS
103
Neonatal meningitis due to group C beta hemolytic streptococcus Prudence Stewardson-Krieger, M.D., and Samuel P. Gotoff, M.D.,* Chicago, Ill.
SERIOUS NEWBORN INFECTIONS with Lancefield streptococcal groups A, B, D, and G have been recorded. '-:' Drusin and associates 4 reported an episode of nursery colonization with Lancefield group C, but, to our knowledge, disease in the newborn infant with this organism has not been previously described, despite its recognized pathogenicity and occasional association with puerperal sepsis? "-" This report deals with a case of neonatal septicemia and meningitis caused by beta hemolytic streptococci group C. CASE REPORT A 14-day-old, 3,180-gm male infant was admitted with a 24hour history of lethargy, irritability, and anorexia. Pregnancy, delivery, and previous neonatal course had been unremarkable. Examination revealed a lethargic infant with a weak cry and a poor sucking reflex. Temperature was 101.6~ pulse, 174 per minute; respirations, 92 per minute. The lungs were clear, the neck supple, and the anterior fontanelle soft and flat. The head circumference was at the fiftieth percentile for age. The rest of the physical examination was within normal limits. The results of the chest roentgenogram and urinalysis were normal. The hemoglobin was 14 gm/dl; the white blood count was 2,300/mm ~ with 35% polymorphonuclear leukocytes, 28% band forms, 26% lymphocytes, 6% monocytes, 2% eosinophils, 2% metamyelocytes, and 1% myelocytes. The cerebrospinal fluid contained numerous polymorphonuclear leukocytes and grampositive cocci. Cultures of blood and spinal fluid grew bacitracinresistant, beta hemolytic streptococci serologically identified as Lancefield group C. Cultures of the mother's vagina failed to grow this organism. The infant was treated with intravenous penicillin G, 150.000 From the Division o f Infectious Diseases, Department o f Pediatrics, Michael Reese Hospital and Medical Center. *Reprint address: Department of Pediatrics, Michael Reese Hospital and Medical Center, 29th St. and Ellis Ave., Chicago, IL 60616.
U/kg/day for 14 days. On the evening of admission, the patient experienced generalized tonic-clonic seizures; therapy with phenobarbital was initiated. The patient's seizure activity continued for seven days, despite adequate serum phenobarbital levels. An electroencephalogram obtained on the eleventh hospital day was compatible with a paroxysmal disorder. The infant improved progressively throughout his hospitalization and was seizure-free by the tenth hospital day. On the twenty-second hospital day, transillumination of the infant's skull showed increased light transmission over the left hemisphere. A brain scan revealed increased uptake over the left hemisphere with slightly decreased uptake on the right. A subdural tap produced 3 ml of sterile, clear, yellow fluid with a protein content of 866 mg/dl. The infant was discharged in good condition on the twenty-seventh hospital day: the weight and head circumference were each in the third percentile. At age three months, the infant's head circumference was in the third percentile, length in the tenth percentile, and weight in the twenty-fifth percentile. Developmental examination revealed an infant functioning in the low range of normal for age. COMMENT Several streptococcal groups, including A, B, C, D, E, F, and G, ...... can colonize the female genital tract and cause puerperal sepsis. Although we did not demonstrate group C colonization of the maternal vagina in the present case, this source of acquisition is of obvious importance in the epidemiology of newborn infections. Neonatal infections with groups A, B, D, and G are known to occur, '-:~ but a review of the literature did not reveal any report of group C neonatal sepsis. In 1973, Drusin and associates ~ recorded colonization in a nursery with group C streptococci, but none o f the infants were ill. In addition to the female vagina, the organism has been cultured from normal skin and the p h a r y n x ? : ' Cases of endocarditis secondary to this organism have been reported and, in two of these cases, the patients had histories of septic abortion5 The group C
Vol. 90, No. 1, pp. 103-104
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Stewardson-Krieger and Gotoff
streptococcus has also been a causative agent in cases of exudative pharyngitis, soft tissue infection, pulmonary infection, osteomyelitis, and urinary tract infection.'. ~'. ~A 1969 report of an epidemic of pharyngitis due to group C streptococci demonstrated a high incidence of postinfection glomerulonephritis," an interesting finding in view of the antigenic similarities between Lancefield groups C and A.' Although blood isolates of group C have been recorded, 1 we know of no previous case in which the human cerebrospinal fluid was the source of this organism. The importance of accurate serologic identification of beta hemolytic streptocci has been previously emphasized.2.4 Since group C isolates can be bacitracinsensitive,' ~ it is possible that infections with this agent have been misdiagnosed as Group A. With increasing utilization of serologic testing for the identification of beta hemolytic streptocci, recognition of the role of nongroup A beta hemolytic streptococci in human infection is likely to increase. REFERENCES
1. Duma RJ, Weisberg AN, Medrek TF, and Kunz LJ: Streptococcal infections: A bacteriologic and clinical study of streptococcal bacteremia, Medicine 48:87, t969.
The Journal of Pediatrics January 1977
2. Baker,CJ: Unusual occurrence of neonatal septicemia due to group G streptococcus, Pediatrics 53:568, 1974. 3. Franciosi RA, Knostman JD, and Zimmerman RA: Group B streptococcal neonatal and infant infections, J PEDIATR 82:707, 1973. 4. Drusin LM, Ribble JC, and Topf B: Group C streptococcal colonization in a newborn nursery, Am J Dis Child 125:820, 1973. 5. Hutchinson RI: Pathogenicity of group C (Lancefield) haemolytic streptococcus, Br Med J 2:575, 1946. 6. Lancefield RC, and Hare R: The serological differentiation of pathogenic and non-pathogenic strains of hemolytic streptococci from parturient women, J Exp Med 61:335, 1935. 7. Finnegan P, Fitzgerald MXM, Cumming G, and Geddes AM: Lancefield group C endocarditis, Thorax 29:245, 1974. 8. Feingold DS, Stagg NL, and Kunz LJ: Extrarespiratory streptococcal infections: Importance of the various serologic groups, N Engl J Med 275:356, 1966. 9. Duca E, Teodorovici G, Radu C, Vita A, TalasmanNiculescu P, Bernescu E, Feldi C, and Rosca V: A new nephritogenic streptococcus, J Hyg (Camb) 67:691, 1969.
103
Neonatal meningitis due to group C beta hemolytic streptococcus Prudence Stewardson-Krieger, M.D., and Samuel P. Gotoff, M.D.,* Chicago, Ill.
SERIOUS NEWBORN INFECTIONS with Lancefield streptococcal groups A, B, D, and G have been recorded. '-:' Drusin and associates 4 reported an episode of nursery colonization with Lancefield group C, but, to our knowledge, disease in the newborn infant with this organism has not been previously described, despite its recognized pathogenicity and occasional association with puerperal sepsis? "-" This report deals with a case of neonatal septicemia and meningitis caused by beta hemolytic streptococci group C. CASE REPORT A 14-day-old, 3,180-gm male infant was admitted with a 24hour history of lethargy, irritability, and anorexia. Pregnancy, delivery, and previous neonatal course had been unremarkable. Examination revealed a lethargic infant with a weak cry and a poor sucking reflex. Temperature was 101.6~ pulse, 174 per minute; respirations, 92 per minute. The lungs were clear, the neck supple, and the anterior fontanelle soft and flat. The head circumference was at the fiftieth percentile for age. The rest of the physical examination was within normal limits. The results of the chest roentgenogram and urinalysis were normal. The hemoglobin was 14 gm/dl; the white blood count was 2,300/mm ~ with 35% polymorphonuclear leukocytes, 28% band forms, 26% lymphocytes, 6% monocytes, 2% eosinophils, 2% metamyelocytes, and 1% myelocytes. The cerebrospinal fluid contained numerous polymorphonuclear leukocytes and grampositive cocci. Cultures of blood and spinal fluid grew bacitracinresistant, beta hemolytic streptococci serologically identified as Lancefield group C. Cultures of the mother's vagina failed to grow this organism. The infant was treated with intravenous penicillin G, 150.000 From the Division o f Infectious Diseases, Department o f Pediatrics, Michael Reese Hospital and Medical Center. *Reprint address: Department of Pediatrics, Michael Reese Hospital and Medical Center, 29th St. and Ellis Ave., Chicago, IL 60616.
U/kg/day for 14 days. On the evening of admission, the patient experienced generalized tonic-clonic seizures; therapy with phenobarbital was initiated. The patient's seizure activity continued for seven days, despite adequate serum phenobarbital levels. An electroencephalogram obtained on the eleventh hospital day was compatible with a paroxysmal disorder. The infant improved progressively throughout his hospitalization and was seizure-free by the tenth hospital day. On the twenty-second hospital day, transillumination of the infant's skull showed increased light transmission over the left hemisphere. A brain scan revealed increased uptake over the left hemisphere with slightly decreased uptake on the right. A subdural tap produced 3 ml of sterile, clear, yellow fluid with a protein content of 866 mg/dl. The infant was discharged in good condition on the twenty-seventh hospital day: the weight and head circumference were each in the third percentile. At age three months, the infant's head circumference was in the third percentile, length in the tenth percentile, and weight in the twenty-fifth percentile. Developmental examination revealed an infant functioning in the low range of normal for age. COMMENT Several streptococcal groups, including A, B, C, D, E, F, and G, ...... can colonize the female genital tract and cause puerperal sepsis. Although we did not demonstrate group C colonization of the maternal vagina in the present case, this source of acquisition is of obvious importance in the epidemiology of newborn infections. Neonatal infections with groups A, B, D, and G are known to occur, '-:~ but a review of the literature did not reveal any report of group C neonatal sepsis. In 1973, Drusin and associates ~ recorded colonization in a nursery with group C streptococci, but none o f the infants were ill. In addition to the female vagina, the organism has been cultured from normal skin and the p h a r y n x ? : ' Cases of endocarditis secondary to this organism have been reported and, in two of these cases, the patients had histories of septic abortion5 The group C
Vol. 90, No. 1, pp. 103-104
10 4
Stewardson-Krieger and Gotoff
streptococcus has also been a causative agent in cases of exudative pharyngitis, soft tissue infection, pulmonary infection, osteomyelitis, and urinary tract infection.'. ~'. ~A 1969 report of an epidemic of pharyngitis due to group C streptococci demonstrated a high incidence of postinfection glomerulonephritis," an interesting finding in view of the antigenic similarities between Lancefield groups C and A.' Although blood isolates of group C have been recorded, 1 we know of no previous case in which the human cerebrospinal fluid was the source of this organism. The importance of accurate serologic identification of beta hemolytic streptocci has been previously emphasized.2.4 Since group C isolates can be bacitracinsensitive,' ~ it is possible that infections with this agent have been misdiagnosed as Group A. With increasing utilization of serologic testing for the identification of beta hemolytic streptocci, recognition of the role of nongroup A beta hemolytic streptococci in human infection is likely to increase. REFERENCES
1. Duma RJ, Weisberg AN, Medrek TF, and Kunz LJ: Streptococcal infections: A bacteriologic and clinical study of streptococcal bacteremia, Medicine 48:87, t969.
The Journal of Pediatrics January 1977
2. Baker,CJ: Unusual occurrence of neonatal septicemia due to group G streptococcus, Pediatrics 53:568, 1974. 3. Franciosi RA, Knostman JD, and Zimmerman RA: Group B streptococcal neonatal and infant infections, J PEDIATR 82:707, 1973. 4. Drusin LM, Ribble JC, and Topf B: Group C streptococcal colonization in a newborn nursery, Am J Dis Child 125:820, 1973. 5. Hutchinson RI: Pathogenicity of group C (Lancefield) haemolytic streptococcus, Br Med J 2:575, 1946. 6. Lancefield RC, and Hare R: The serological differentiation of pathogenic and non-pathogenic strains of hemolytic streptococci from parturient women, J Exp Med 61:335, 1935. 7. Finnegan P, Fitzgerald MXM, Cumming G, and Geddes AM: Lancefield group C endocarditis, Thorax 29:245, 1974. 8. Feingold DS, Stagg NL, and Kunz LJ: Extrarespiratory streptococcal infections: Importance of the various serologic groups, N Engl J Med 275:356, 1966. 9. Duca E, Teodorovici G, Radu C, Vita A, TalasmanNiculescu P, Bernescu E, Feldi C, and Rosca V: A new nephritogenic streptococcus, J Hyg (Camb) 67:691, 1969.
