Group C streptococcal endocarditis presenting as clinical meningitis: Report of a case and review of the literature

Lancefield group C streptococci are known to be pathogenic in a number of animal species, but cause human disease much less commonly than do streptococci of scrogroups A or B. Reported cases of bacteremic infection, pneumonia or meningitis in humans have been very severe with a grave prognosis. The authors describe a patient who presented with classic clinical and laboratory evidence of bacterial meningitis which proved to be a complication of endocarditis caused by a group C streptococcus. This is the first reported case in which meningitis was the presenting manifestation of group C streptococcal endocarditis and is only the second case in which group C streptococcal meningitis and endocarditis have been associated in the same patient. A total of 13 cases of group C streptococcal meningitis have now been reported in the medical literature. Five of these patients died, and four others recovered only to be left with neurological sequelae. The current case confirms the seriousness of group C streptococcal infections in humans. Such infections are associated with a poor prognosis despite apparently adequate antimicrobial therapy.     

Group B streptococcal endocarditis: report of seven cases and review of the literature, 1962-1985

Infective endocarditis is an uncommon manifestation of group B streptococcal disease. Seven cases of group B streptococcal endocarditis are reported herein. Another fifty-five cases published in the literature since 1962 are reviewed: the male to female ratio was 1.4:1. The average age was 53.8 years, and 45% of patients were 60 years of age or older. Two cases of nonsocomial endocarditis and two cases of polymicrobial endocarditis were identified. There were five cases of prosthetic valve endocarditis. Mitral and aortic valvular involvement were present in 48% and 29% of cases, respectively. Underlying heart disease was found in more than half of the cases. Rheumatic heart disease was the commonest underlying cardiac condition. Noncardiac underlying conditions included diabetes mellitus, alcoholism, pregnancy, intravenous drug abuse, and genitourinary disease. Onset was varied as was initial presentation of the disease. Large arterial thrombi were common. Overall mortality was 43.5%. Penicillin is the treatment of choice for group B streptococcal endocarditis. However, based on in vitro and in vivo studies as well as case reports, some authors feel that the combination of penicillin and an aminoglycoside is a superior regimen. Cephalothin or vancomycin are alternatives for patients who are allergic to penicillin.     

Isolated native tricuspid valve endocarditis caused by viridans streptococcus

The present report describes a case of native tricuspid valve endocarditis caused by viridans group streptococcus in a 43-year-old man who had recently undergone dental extraction. The patient had no history of intravenous drug use, heart disease or right heart catheterization. Although there have been scattered reports of unusual organisms, to the authors'' knowledge, this is the first case of viridans group streptococcal endocarditis involving only the tricuspid valve after dental manipulation.Key Words: Tricuspid valve endocarditis, Viridans streptococcusIsolated native tricuspid valve endocarditis (TVE) accounts for only 5% to 10% of all cases of infective endocarditis (1,2) and is rarely seen in the absence of intravenous drug use (IDU) or intracardiac catheterization or cardiac anomalies (3,4). The present report describes a case of isolated viridans streptococcal TVE after dental manipulation in a nonintravenous drug user without underlying cardiac disease or central venous catheterization. We are not aware of any cases reported in the English literature of isolated native TVE caused by viridans streptococcal species after dental procedures. The expedient identification of patients with TVE in the absence of predisposing factors can be difficult, and thus delay in diagnosis may delay appropriate therapeutic intervention.     

Replacement of the mitral valve in an infant with group B streptococcal endocarditis

Endocarditis due to group B streptococcus is very rare in infants, and may be associated with significant morbidity and mortality. Review of the literature reveals only a single reported case of an infant with this type of streptococcal endocarditis involving the mitral valve. This infant had underlying congenital heart disease, and died shortly after catheterization. We now report group B streptococcal endocarditis occurring in an infant with a structurally normal heart who was treated successfully by replacement of the mitral valve.     

Endocarditis with myocardial abscesses and pericarditis in an adult: group B Streptococcus as a cause.

Group B beta-hemolytic Streptococcus, S agalactiae, is an uncommon cause of endocarditis in adults. We present the clinical, laboratory, and postmortem findings of an adult patient with group B streptococcal endocarditis and major arterial emboli. What to our knowledge are previously unreported features are purulent pericarditis and myocardial abscesses. Twenty-five cases of endocarditis caused by group B Streptococcus that are reported in the literature are reviewed.     

Group B streptococcal endocarditis of tricuspid valve

We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.     

Group B streptococcal bacteremia in a community teaching hospital

Group B streptococcal bacteremia outside the perinatal setting is not commonly emphasized. This report reviews all episodes of group B streptococcal bacteremia during a four and a half year period in a large community teaching hospital. Fourteen episodes occurred in neonates, four in parturient women, and 28 in other adults. Bacteremic adults were usually elderly with an average age of 68 years. Group B streptococcal bacteremia occurred in adults with various underlying diseases, including diabetes mellitus, liver disease, peripheral vascular disease, and hematologic disease, and in those receiving long-term steroid therapy. Infections causing group B streptococcal bacteremia in adults included decubitus ulcers, pneumonia, endocarditis, cellulitis, arthritis, osteomyelitis, and meningitis. Thirteen of 28 episodes of group B streptococcal bacteremia in adults were hospital-acquired. Overall mortality in adults was 70 percent. Group B streptococcal bacteremia in adults outside of the perinatal setting is associated with significant underlying diseases and has a high mortality.     

Group B streptococcal endocarditis mimicking mitral valve myxoma

A patient with group B streptococcal endocarditis and large vegetations resembling mitral valve myxoma is described. Group B streptococcal endocarditis and the differential diagnosis of vegetations and cardiac tumors are briefly reviewed.     

Isolated native tricuspid valve endocarditis caused by viridans streptococcus.

The present report describes a case of native tricuspid valve endocarditis caused by viridans group streptococcus in a 43-year-old man who had recently undergone dental extraction. The patient had no history of intravenous drug use, heart disease or right heart catheterization. Although there have been scattered reports of unusual organisms, to the authors' knowledge, this is the first case of viridans group streptococcal endocarditis involving only the tricuspid valve after dental manipulation.     

Group B streptococcal infective endocarditis

From 1970 to 1983, five patients with group B streptococcal endocarditis were treated at the Mayo Clinic, Rochester, Minn. The minimal inhibitory concentration and the minimal bactericidal concentration of penicillin were 0.09 microgram/mL or less and 1.56 micrograms/mL or less, respectively. The in vitro activity of cefazolin against group B streptococci was similar to that of penicillin. In three of the five cases, penicillin and streptomycin acted synergistically in vitro against group B streptococci. Four of the five patients were cured, three by use of an aminoglycoside combined with penicillin, ampicillin, or vancomycin. Three of the five patients had multiple large systemic emboli, and one of the three died of brain-stem infarct. Penicillin alone or in combination with an aminoglycoside is effective therapy for group B streptococcal endocarditis. Patients unable to tolerate penicillin may be treated with cefazolin or vancomycin. Clindamycin therapy should be avoided in patients with endocarditis caused by strains that are tolerant in vitro to clindamycin.     

Prevention of group B streptococcal infection.

Group B streptococci continue to be major perinatal pathogens, both for mothers and their infants, and are associated with significant morbidity, mortality, and its attendant cost to society. Approaches to prevention are directed toward either eliminating exposure to the organism or enhancing host resistance, that is, chemoprophylaxis and immunoprophylaxis. Intrapartum chemoprophylaxis has been shown to effectively interrupt vertical transmission of group B streptococci from the genitally colonized mother to the infant and to decrease the incidence of both maternal and early-onset neonatal group B streptococcal disease. To avoid unnecessarily exposing large numbers of colonized women to antibiotics, only those with defined risk factors should be selected for intrapartum chemoprophylaxis. This regimen is ampicillin given intravenously, 2 g initially at onset of labor or rupture of membranes, followed by 1 g every 4 hours until delivery. Risk factors include premature onset of labor or rupture of membranes before 37 weeks' gestation, rupture of membranes of more than 12 hours, intrapartum fever, group B streptococcal bacteriuria, or having previously delivered an infant with group B streptococcal disease. Detection of anogenital colonization is accomplished either by culture late in the second or early in the third trimester or by intrapartum group B streptococcal antigen testing of vaginal swabs from those previously culture-negative or not cultured. Although this approach combines the advantages of several proposed strategies, it will still miss those cases of group B streptococcal disease developing in the absence of discernible risk factors. Intrapartum prophylaxis does not prevent late-onset group B streptococcal disease. Prenatal and postnatal chemoprophylaxis have not been shown to be effective. Symptomatic infants born to mothers given chemoprophylaxis should be evaluated for neonatal sepsis and treated accordingly. This approach is also suggested for asymptomatic premature infants, those whose mothers have not received adequate prophylaxis or have previously delivered infants with group B streptococcal disease, and for twin siblings of infants developing group B streptococcal disease. Successful implementation of this approach may be limited by the availability and sensitivity of the rapid antigen test used. Immunoprophylaxis, and active immunization in particular, is the most promising method of preventing perinatal group B streptococcal disease in mothers and their infants, including late-onset disease. Immunization of pregnant women with type III polysaccharide vaccine has resulted in adequate provision of functional antibody to the infants born to responders.(ABSTRACT TRUNCATED AT 400 WORDS)     

Serious infections due to group G streptoccocci: Report of 15 cases with in vitro-in vivo correlations

Serious infections due to group G streptococci have been infrequently reported. Fifteen such cases are described. Endovascular infection, particularly endocarditis, and septic arthritis were the most common clinical syndromes observed. Despite exquisite in vitro sensitivity of group G streptococci to penicillin G, the in vivo clinical response was disappointing in six of nine patients with either endocarditis or septic arthritis. The group G streptococcal isolates from the patients in this study were uniformly sensitive to the inhibitory and killing action of penicillin G, ampicillin, cefotaxime, cephalothin, cefoxitin, and vancomycin. In contrast, clindamycin, erythromycin, and chloramphenicol had relatively poor bactericidal activity against these strains, including several “tolerant” strains. Timed-kill studies with penicillin G revealed impaired killing of group G streptococci at in vitro conditions of high inocula and stationary growth phases. This may partially explain the poor clinical responses in cases of group G streptococcal endocarditis.     

Group G streptococcal endocarditis: two case reports, a review of the literature and recommendations for treatment

Two cases of endocarditis caused by a group G streptococcus are reported and the literature on group G streptococcal endocarditis is reviewed. The onset of illness is usually acute and the portal of entry for the organism through the skin. The left side of the heart is mainly involved and in about 50% cases the endocarditis arises on a normal valve. Most patients develop complications, both embolic and cardiac, and the mortality is high (36%). We suggest that patients with proven group G streptococcal endocarditis should be treated with large doses of benzyl penicillin and with an aminoglycoside for not less than 4 weeks. Patients with complications should be referred to a cardiothoracic centre. We should be glad to know details of complications, treatment and outcome in other cases of group G streptococcal endocarditis.     

Group G streptococcal endocarditis and bacteremia

This report describes fifteen recent cases of group G streptococcal bacteremia in patients with acute illnesses. Seven patients had acute endocarditis (47 percent). Four deaths occurred, and four patients had significant clinical complications during prolonged stormy courses. This series indicates a relatively high incidence of infective endocarditis in patients with group G streptococcal bacteremia, which is at variance with recent reports. Group G streptococcal bacteremia (with or without endocarditis) is a serious infection that often follows a hectic course with significant morbidity and mortality. The need for prompt recognition and aggressive treatment of this infection is underscored.     

Endocarditis caused by group A beta-hemolytic Streptococcus in an infant: case report and review.

Acute bacterial endocarditis in the absence of underlying heart disease is rare. We report the occurrence of endocarditis caused by group A beta-hemolytic Streptococcus (GABHS), following varicella, in a 5-month-old child without heart disease. In addition to this child, seven other children with endocarditis caused by GABHS have been reported since 1966, six of whom did not have preexisting heart disease. In one of these children, GABHS endocarditis was preceded by varicella. These cases indicate that GABHS is capable of causing endocarditis in the absence of heart disease, and they provide further evidence that varicella is an important risk factor for invasive GABHS infections.     

Endocardite tricuspide du post-partum à streptocoque B

The B streptococcal endocarditis are very rare. They primarily affect the left heart valves, the achievement of the tricuspid valve is exceptional. We report a young patient aged of 36 years who presented in postpartum a tricuspid endocarditis with streptococcus B. She was treated by third-generation cephalosporin and aminoglycoside. The evolution after 5 days of antibiotic therapy was marked by a rapid valvular destruction with worsening tricuspid insufficiency leading to death of the patient. This is the 23rd case of tricuspid endocarditis streptococcal B reported in the literature. The mortality of this disease reached 36% in the absence of surgical treatment. The medico-surgical approach is the treatment of choice for these patients.     

Endocarditis caused by penicillin-resistant viridans streptococci: 2 cases and controversies in therapy.

Although penicillin-resistant viridans streptococci have been isolated from samples from the mouth, blood, and wounds in increasing numbers, viridans streptococci isolated from patients with endocarditis have remained sensitive to penicillin for the past 5 decades. We report the cases of 2 patients with penicillin-resistant viridans streptococcal endocarditis, review 6 other cases from the literature, and summarize 2 studies that used an animal model of penicillin-resistant viridans streptococcal endocarditis.     

Serious infections caused by Streptococcus milleri

Viridans streptococci continue to be the most common etiologic agents in bacterial endocarditis. The spectrum of diseases other than endocarditis caused by these organisms, however, has received sparse attention. Moreover, little clinical information is available concerning the individual viridans streptococcal species. During the 16 months of this study, one species of viridans streptococci, Streptococcus milleri, caused a surprising number of clinically significant suppurative infections. Clinical syndromes included the following: abscesses, 10 cases; peritonitis, four cases; endocarditis, three cases; cholangitis, empyema and cellulitis, one case each. A gastrointestinal source was apparent in eight of these 20 cases. Review of 58 cases of viridans streptococcal endocarditis demonstrated that although Strep. milleri was an infrequent cause of endocarditis, this species was associated with an unusual frequency of suppurative complications. Our experience suggests that Strep. milleri may be more commonly associated with serious suppurative infections than other viridans streptococci and that species identification may be a clinically useful procedure.     

Group B streptococcal disease in UK and Irish infants younger than 90 days

The incidence, morbidity, and mortality of group B streptococcal disease in the UK and Republic of Ireland are largely unknown. Between Feb 1, 2000, and Feb 28, 2001, we identified cases of invasive group B streptococcal disease in infants younger than 90 days through surveillance involving paediatricians, microbiologists, and parents. 568 cases were identified, equivalent to a total incidence of 0.72 per 1000 live-births (95% CI 0.66-0.78); the incidence for early-onset disease (n=377) was 0.48 per 1000 (0.43-0.53), and for late-onset disease (n=191) was 0.24 per 1000 (0.21-0.28). Risk factors were identifiable for 218 (58%) cases of early-onset disease. 53 infants died (overall 9.7%). We have established the minimum current burden of group B streptococcal disease in UK and Irish infants. This information will assist in the formulation of guidelines for prevention of this disease.     

Abiotrophia Endocarditis in Children with No Underlying Heart Disease: A Rare but a Virulent Organism

Infective endocarditis is extremely rare in children with structurally normal hearts. The most common etiological agents are staphylococcal and streptococcal species. Nutritionally variant streptococci also classified as Abiotrophia species are a group of fastidious organisms that account for only 5% to 6% of all cases of culture‐negative infective endocarditis. Only seven cases of Abiotrophia infective endocarditis have been previously reported in children with no underlying structural heart disease. We report two cases of Abiotrophia infective endocarditis in children without any predisposing factors. Both patients presented with nonspecific symptoms leading to delay in diagnosis. While bacteriological clearance was achieved in both cases, both had a complicated course including development of brain mycotic aneurysms, splenic infarction, renal failure, and irreversible damage to the mitral valve. Both patients required surgical removal of the native mitral valve and replacement. We also present review of seven cases with similar diagnosis published previously in literature and highlight important differences. Our cases highlight special challenges in management of Abiotrophia endocarditis in pediatric patients. As the organism may not be isolated in routine culture media, may present with atypical clinical symptoms and may have a complicated course even without antibiotic failure, a high index of suspicion should be maintained in children with subacute symptoms even with no underlying structural cardiac disease.