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Pediatric epiglottitis caused by group G beta-hemolytic Streptococcus

2003; Lippincott Williams & Wilkins; Volume: 22; Issue: 9 Linguagem: Inglês

10.1097/01.inf.0000086421.57385.b1

1532-0987

Glenn Isaacson, David Isaacson,

Infective Endocarditis Diagnosis and Management

A 4-year-old boy developed epiglottitis with fever, sore throat and inspiratory stridor over the course of an afternoon. By direct epiglottic culture group G Streptococcus was identified as the pathogen. The presentation and clinical course of epiglottitis caused by each of the beta-hemolytic streptococcal pathogens is similar, and each is very different from Haemophilus influenzae type b disease. The widespread use of immunizations against Haemophilus influenzae type b (Hib) has significantly decreased the incidence of meningitis and sepsis caused by this invasive organism. 1 A welcomed side effect of this immunization program has been a 10-fold decrease in the incidence of epiglottitis (supraglottitis). 2, 3 Hib was the dominant cause of epiglottitis in the early 1980s with other organisms accounting for ∼1% of cases. 4 As Hib epiglottis has disappeared, other organisms including Streptococcus pneumoniae, 5Haemophilus parainfluenzae, 6Staphylococcus aureus, 7Candida spp., 8 viral pathogens 9, 10 and group A, 11 B 12 and C 13 streptococci have emerged as increasingly likely etiologies for this disease. Epiglottitis may present differently when these alternative microorganisms are the cause. Report of a case. A 4-year-old boy developed sore throat and fever over the course of a day. By evening his temperature was 40°C, and he had developed low pitched inspiratory stridor. On arrival at the emergency room he was quiet, flushed and frightened-looking and preferred a sitting posture. He would not speak but was not drooling. Radiographs were not attempted. The emergency physicians suspected epiglottitis, and the child was transferred to the operating room with anesthesia staff and a pediatric otolaryngologist in attendance at all times. Anesthesia was induced by mask while he sat in his mother's arm. Direct laryngoscopy revealed marked edema of the lingual surface of the epiglottis and the aryepiglottic folds without purulence or a "cherry-red" appearance. He was intubated orally with an age-appropriate endotracheal tube. Blood cultures, complete blood count and direct epiglottic culture were performed before the administration of antibiotics. High dose intravenous cefuroxime was administered, and the patient was transferred to a pediatric intensive care unit. An air leak developed around the endotracheal tube by the second hospital day, but laryngoscopy revealed persistent epiglottic edema. The child was extubated on his sixth hospital day. He developed muscle weakness from paralytic agents and immobilization but quickly recovered with physical therapy. Final blood cultures were negative. After incubation of the epiglottic swab specimen on 5% sheep blood agar plates at 37°C in 5% carbon dioxide, the predominant colonies found were large and beta-hemolytic. Samples of these colonies were transferred to the PathoDx latex agglutination system (Diagnostic Products Corp., Los Angeles, CA) and were identified as type G streptococci. Further species identification was not performed. The isolate was susceptible to all common antibiotics. Discussion. In 1933 Rebecca Lancefield divided the streptococci into 15 groups (groups A to O) based on the specific carbohydrates that could be extracted from their cell walls. Among these A, B, C and G are the beta-hemolytic groups most likely to cause bacteremia in humans. Groups A and B are familiar pathogens, but group G has been recognized as an important invasive organism chiefly in the last decade. Although group G bacteremia is most common in elderly hospitalized patients, 14 cellulitis, endocarditis, skin and wound infections, meningitis, arthritis, osteomyelitis, pneumonia and pharyngitis from group G Streptococcus have been reported in normal hosts. 15 It is not clear whether the true incidence of group G streptococcal infections is increasing or whether it is identified more often now that accurate latex agglutination kits are readily available in most laboratories. An epidemiologic study at 1 hospital in Israel showed an increase from 0 to 13 cases of invasive group G Streptococcus between 1990 and 1999. The same bacteriologic methods were used during the study period, arguing for a true increase in frequency. 16 Classically epiglottitis caused by Hib is a fulminant infection; a previously healthy child can be near death in a few hours. By the same token, when given high doses of effective antibiotics, children with Hib epiglottitis usually can be extubated within 24 to 48 h. In the reported cases of epiglottitis caused by the other three beta-hemolytic streptococci that are human pathogens, the onset of disease was more gradual, and the mean duration of intubation was 6 days. 11–13 This was true for our patient as well. Similarly, the cherry-red epiglottis of Hib infection was replaced by a pale edematous one in described cases of streptococcal disease. Clearly there is an increasing need for diagnostic laryngoscopy, both to identify epiglottitis and to decide when extubation is appropriate. Most group G streptococci remain very sensitive to penicillin and cephalosporins, the commonly used agents for empiric treatment of epiglottitis. There are reports of aminoglycoside, erythromycin and vancomycin resistance in certain group G isolates, 17–19 and such agents should be avoided for monotherapy of epiglottitis.