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Endocarditis Due to Beta-Hemolytic Streptococci

1992; Elsevier BV; Volume: 102; Issue: 2 Linguagem: Inglês

10.1378/chest.102.2.333

1931-3543

Chatrchai Watanakunakorn,

Infective Endocarditis Diagnosis and Management

Alpha-hemolytic (viridans) streptococci, Streptococcus bovis, and enterococci are common causes of infective endocarditis, while beta-hemolytic streptococci are not. However, over the years endocarditis due to beta-hemolytic streptococci has been recognized. With the use of Lancefield serogrouping according to cell wall antigens, beta-hemolytic streptococci may be identified as group A, B, C, or G. Group D streptococci may be alpha-hemolytic, beta-hemolytic, or non-hemolytic. Most microbiology laboratories are now routinely serogrouping beta-hemolytic streptococci isolated from blood cultures. Consequently, septicemia and endocarditis due to Group A, B, C, and G streptococci are being reported.1Skogberg K Simonen H Renkonen OV Valtonen W Beta-hemolytic group A B, C and G streptococcal septicemia: a clinical study.Scand J Infect Dis. 1988; 20: 119-125Crossref PubMed Scopus (64) Google ScholarThere is only one species of group A streptococci, Streptococcus pyogenes, which is known to be a major cause of pharyngitis, cellulitis, and pyoderma, although it is capable of causing other infections, including septicemia with shock.2Burkert T Watanakunakorn C Group A streptococcal bacteremia in a community teaching hospital—1980-1989.Clin Infect Dis. 1992; 14: 29-37Crossref PubMed Scopus (46) Google Scholar, 3Stevens DL Tanner MH Winship J et al.Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A..N Engl J Med. 1989; 321: 1-7Crossref PubMed Scopus (969) Google Scholar Endocarditis caused by group A streptococci is rather uncommon.4Burkert T Watanakunakorn C Group A streptococcus endocarditis: report of five cases and review of literature.J Infect. 1991; 23: 307-316Abstract Full Text PDF PubMed Scopus (22) Google Scholar There have been only 36 published cases of endocarditis due to group A streptococci with clinical details, including 22 cases in intravenous drug abusers (IVDAs). The disease was acute and often involved a normal heart valve. The mortality was 21 percent, but only 9 percent in the IVDAs.4Burkert T Watanakunakorn C Group A streptococcus endocarditis: report of five cases and review of literature.J Infect. 1991; 23: 307-316Abstract Full Text PDF PubMed Scopus (22) Google Scholar Among the beta-hemolytic streptococci, it is the most common cause of endocarditis in IVDAs.Group B streptococcus (Streptococcus agalactiae) is best known for causing neonatal septicemia and meningitis, although it can cause serious illnesses in adults, including septicemia and endocarditis.5Gallagher PG Watanakunakorn C Group B streptococcal bacteremia in a community teaching hospital.Am J Med. 1985; 78: 795-800Abstract Full Text PDF PubMed Scopus (76) Google Scholar, 6Gallagher PG Watanakunakorn C Group B streptococcal endocarditis: report of seven cases and review of the literature, 1962-1985.Rev Infect Dis. 1986; 8: 175-188Crossref PubMed Scopus (79) Google Scholar, 7Scully BE Spriggs D Neu HC Streptococcus agalactiae (group B) endocarditis: a description of twelve cases and reivew of the literature.Infection. 1987; 15: 169-176Crossref PubMed Scopus (54) Google Scholar, 8Watanakunakorn C Habte-Gabr E Group B streptococcal endocarditis of tricuspid valve.Chest. 1991; 100: 569-571Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Among the beta-hemolytic streptococci, it is the most commonly reported cause of endocarditis. Since 1962, there have been 100 reported cases of group B streptococcal endocarditis, including eight cases in IVDAs, with an overall mortality of 41 percent and a mortality in IVDAs of 25 percent. Group B streptococci cause acute endocarditis and are capable of causing right-sided endocarditis in individuals who are not IVDAs.8Watanakunakorn C Habte-Gabr E Group B streptococcal endocarditis of tricuspid valve.Chest. 1991; 100: 569-571Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Many patients have underlying diseases, such as diabetes mellitus, malignancy, and alcoholism. Large arterial emboli are common.5Gallagher PG Watanakunakorn C Group B streptococcal bacteremia in a community teaching hospital.Am J Med. 1985; 78: 795-800Abstract Full Text PDF PubMed Scopus (76) Google ScholarThere are at least three species of group C streptococci: Streptococcus equi, Streptococcus equisimilis, and Streptococcus zooepidemicus. These are pathogens in horses and other animals, but septicemia, meningitis, endocarditis, and other infections in humans have been reported.9Raizes EG Livingston MB Farrar WE Case report: fatal cardiac tamponade in a young man with group C streptococcal endocarditis.Am J Med Sci. 1987; 294: 353-356Crossref PubMed Scopus (7) Google Scholar, 10Bradley SF Gordon JJ Baumgartner DD Marasco WA Kauffman CA Group C streptococcal bacteremia: analysis of 88 cases.Rev Infect Dis. 1991; 13: 270-280Crossref PubMed Scopus (140) Google Scholar There have been 18 well-described cases of group C streptococcal endocarditis, including one case in an IVDA; the mortality was high (41 percent [the single IVDA survived]).Group G streptococci include the large-colony types and the "minuter-colony types, such as Streptococcus anginosus, which is closely related to the group F streptococci. Group G streptococci have been reported to cause serious infections, including arthritis, osteomyelitis, septicemia, and endocarditis.11Burkert T Watanakunakorn C Group G streptococcus septic arthritis and osteomyelitis: report and literature review.J Rheumatol. 1991; 18: 904-907PubMed Google Scholar, 12Venezio FR Gullberg RM Westenfelder GO Phair JP Cook FV Group G streptococcal endocarditis and bacteremia.Am J Med. 1986; 81: 29-34Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 13Smyth EG Pallett AP Davidson RN Group G streptococcal endocarditis: two case reports, a review of the literature and recommendations for treatment.J Infect. 1988; 16: 169-176Abstract Full Text PDF PubMed Scopus (35) Google Scholar Group G streptococci also cause acute endocarditis. Diabetes mellitus, alcoholism, and malignancy are important underlying conditions. There have been 72 well-described cases of group G streptococcal endocarditis, including 20 in IVDAs. The overall mortality was 35 percent; that in IVDAs, 15 percent.In summary, group A, B, C, and G beta-hemolytic streptococci may cause acute endocarditis. Group A, B, C, and G streptococci are all susceptible to penicillin; group A streptococci are the most susceptible. Treatment of endocarditis due to these organisms is high-dose penicillin with an option of adding gentamicin for synergism. Endocarditis caused by group B streptococci is the most common type, and endocarditis caused by group A streptococci is associated with the lowest mortality. Early valve replacement may be indicated in endocarditis caused by group B, C, and G streptococci. Alpha-hemolytic (viridans) streptococci, Streptococcus bovis, and enterococci are common causes of infective endocarditis, while beta-hemolytic streptococci are not. However, over the years endocarditis due to beta-hemolytic streptococci has been recognized. With the use of Lancefield serogrouping according to cell wall antigens, beta-hemolytic streptococci may be identified as group A, B, C, or G. Group D streptococci may be alpha-hemolytic, beta-hemolytic, or non-hemolytic. Most microbiology laboratories are now routinely serogrouping beta-hemolytic streptococci isolated from blood cultures. Consequently, septicemia and endocarditis due to Group A, B, C, and G streptococci are being reported.1Skogberg K Simonen H Renkonen OV Valtonen W Beta-hemolytic group A B, C and G streptococcal septicemia: a clinical study.Scand J Infect Dis. 1988; 20: 119-125Crossref PubMed Scopus (64) Google Scholar There is only one species of group A streptococci, Streptococcus pyogenes, which is known to be a major cause of pharyngitis, cellulitis, and pyoderma, although it is capable of causing other infections, including septicemia with shock.2Burkert T Watanakunakorn C Group A streptococcal bacteremia in a community teaching hospital—1980-1989.Clin Infect Dis. 1992; 14: 29-37Crossref PubMed Scopus (46) Google Scholar, 3Stevens DL Tanner MH Winship J et al.Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A..N Engl J Med. 1989; 321: 1-7Crossref PubMed Scopus (969) Google Scholar Endocarditis caused by group A streptococci is rather uncommon.4Burkert T Watanakunakorn C Group A streptococcus endocarditis: report of five cases and review of literature.J Infect. 1991; 23: 307-316Abstract Full Text PDF PubMed Scopus (22) Google Scholar There have been only 36 published cases of endocarditis due to group A streptococci with clinical details, including 22 cases in intravenous drug abusers (IVDAs). The disease was acute and often involved a normal heart valve. The mortality was 21 percent, but only 9 percent in the IVDAs.4Burkert T Watanakunakorn C Group A streptococcus endocarditis: report of five cases and review of literature.J Infect. 1991; 23: 307-316Abstract Full Text PDF PubMed Scopus (22) Google Scholar Among the beta-hemolytic streptococci, it is the most common cause of endocarditis in IVDAs. Group B streptococcus (Streptococcus agalactiae) is best known for causing neonatal septicemia and meningitis, although it can cause serious illnesses in adults, including septicemia and endocarditis.5Gallagher PG Watanakunakorn C Group B streptococcal bacteremia in a community teaching hospital.Am J Med. 1985; 78: 795-800Abstract Full Text PDF PubMed Scopus (76) Google Scholar, 6Gallagher PG Watanakunakorn C Group B streptococcal endocarditis: report of seven cases and review of the literature, 1962-1985.Rev Infect Dis. 1986; 8: 175-188Crossref PubMed Scopus (79) Google Scholar, 7Scully BE Spriggs D Neu HC Streptococcus agalactiae (group B) endocarditis: a description of twelve cases and reivew of the literature.Infection. 1987; 15: 169-176Crossref PubMed Scopus (54) Google Scholar, 8Watanakunakorn C Habte-Gabr E Group B streptococcal endocarditis of tricuspid valve.Chest. 1991; 100: 569-571Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Among the beta-hemolytic streptococci, it is the most commonly reported cause of endocarditis. Since 1962, there have been 100 reported cases of group B streptococcal endocarditis, including eight cases in IVDAs, with an overall mortality of 41 percent and a mortality in IVDAs of 25 percent. Group B streptococci cause acute endocarditis and are capable of causing right-sided endocarditis in individuals who are not IVDAs.8Watanakunakorn C Habte-Gabr E Group B streptococcal endocarditis of tricuspid valve.Chest. 1991; 100: 569-571Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Many patients have underlying diseases, such as diabetes mellitus, malignancy, and alcoholism. Large arterial emboli are common.5Gallagher PG Watanakunakorn C Group B streptococcal bacteremia in a community teaching hospital.Am J Med. 1985; 78: 795-800Abstract Full Text PDF PubMed Scopus (76) Google Scholar There are at least three species of group C streptococci: Streptococcus equi, Streptococcus equisimilis, and Streptococcus zooepidemicus. These are pathogens in horses and other animals, but septicemia, meningitis, endocarditis, and other infections in humans have been reported.9Raizes EG Livingston MB Farrar WE Case report: fatal cardiac tamponade in a young man with group C streptococcal endocarditis.Am J Med Sci. 1987; 294: 353-356Crossref PubMed Scopus (7) Google Scholar, 10Bradley SF Gordon JJ Baumgartner DD Marasco WA Kauffman CA Group C streptococcal bacteremia: analysis of 88 cases.Rev Infect Dis. 1991; 13: 270-280Crossref PubMed Scopus (140) Google Scholar There have been 18 well-described cases of group C streptococcal endocarditis, including one case in an IVDA; the mortality was high (41 percent [the single IVDA survived]). Group G streptococci include the large-colony types and the "minuter-colony types, such as Streptococcus anginosus, which is closely related to the group F streptococci. Group G streptococci have been reported to cause serious infections, including arthritis, osteomyelitis, septicemia, and endocarditis.11Burkert T Watanakunakorn C Group G streptococcus septic arthritis and osteomyelitis: report and literature review.J Rheumatol. 1991; 18: 904-907PubMed Google Scholar, 12Venezio FR Gullberg RM Westenfelder GO Phair JP Cook FV Group G streptococcal endocarditis and bacteremia.Am J Med. 1986; 81: 29-34Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 13Smyth EG Pallett AP Davidson RN Group G streptococcal endocarditis: two case reports, a review of the literature and recommendations for treatment.J Infect. 1988; 16: 169-176Abstract Full Text PDF PubMed Scopus (35) Google Scholar Group G streptococci also cause acute endocarditis. Diabetes mellitus, alcoholism, and malignancy are important underlying conditions. There have been 72 well-described cases of group G streptococcal endocarditis, including 20 in IVDAs. The overall mortality was 35 percent; that in IVDAs, 15 percent. In summary, group A, B, C, and G beta-hemolytic streptococci may cause acute endocarditis. Group A, B, C, and G streptococci are all susceptible to penicillin; group A streptococci are the most susceptible. Treatment of endocarditis due to these organisms is high-dose penicillin with an option of adding gentamicin for synergism. Endocarditis caused by group B streptococci is the most common type, and endocarditis caused by group A streptococci is associated with the lowest mortality. Early valve replacement may be indicated in endocarditis caused by group B, C, and G streptococci.