An Unusual Presentation Of a/3 Hemolytic Group B Streptococcal Infection

By Will iam E. Bomar, Jr., Jerry J. Ferlauto,

and David H. Wells

Greenvil le, South Carol ina

�9 This is a case of Group B streptococcal infec- tion presenting as necrotizing fasciitis in a 5-wk-old infant.

INDEX WORDS: Group B streptococcal disease; necrotizing fasciitis.

G ROUP B Streptococcal (GBS) infections in the neonate are becoming the leading

cause of infection in many nurseries. ~ Early neonatal septicemia and pneumonia and late onset meningitis are the most common types of GBS infection? More recently other types of GBS presentation have been reported. These include septic arthritis, osteomyelitis, ethmoidi- tis and orbital cellulitis and conjunctivitis) 5

A case of/3 hemolytic GBS infection causing septicemia, meningitis and localized gangrene has been encountered at the Special Care Nursery at Greenville General Hospital. This case is an unusual presentation for/3 hemolytic GBS infection.

CASE REPORT

A 5-wk-old, 2183 g, black female infant was transferred to the Greenville General Hospital Regional Special Care Nursery because of shock, apnea, and a swollen face.

This child was an 1150-g first-born twin, delivered at an outlying hospital. Twin no. 2 died of RDS. This child did not develop RDS and remained in the outlying hospital for approximately 33 days. The child was discharged home in "good health" the day before admission to Greenville General Hospital. Twelve hours prior to admission the parents noted the child was listless and had grunting respira- tions. The infant refused her morning feedings and was taken to the emergency room at the referring hospital. Upon arrival at the emergency room, respiratory distress, and a swelling over the right mandible was noted. Temperature on arrival at the emergency room was 33 ~ C (rectal) and the heart rate was 120-130. The infant had a respiratory arrest, was intubated, and transferred on request to Greenville General Hospital Special Care Nursery.

On admission to the Special Care Nursery at Greenville General Hospital, the child was still intubated with minimal response to stimuli. Temperature was 37.4 ~ C (axillary), pulse 180, systolic blood pressure 54 mm Hg. A purple-red swelling was noted extending from the center of the right mandible, under the chin, back to the ear (Fig. 1). This area had increased in size over the preceding hour. Cultures of blood, CSF, and transudate from an incision of the cervico-

mandibular area were obtained. Gram stain of the transu- date revealed gram-positive cocci. The WBC count was 1800. Methicillin and gentamycin had been initiated at the time of pick-up because of the condition of the infant. All cultures subsequently grew/3 hemolytic GBS. At this t ime methicillin and gentamycin were discontinued and aqueous penicillin was continued for 3 wk.

During the course of antibiotics, the infant clinically improved. The child was weaned from the ventilator in 2 days. Within 7 days her blood count was normal. Repeat cultures from blood and CSF were negative. The child began nippling well after 6 days. By 10 days after hospitalization, the gangrenous area had formed a well defined eschar and the child was taken to surgery for debridement and skin grafting of the area 3 wk after admission.

The appearance of the lesion exhibited characteristics consistent with progressive synergistic gangrene but at no time did cultures reveal any gram-negative organisms. The mature eschar involved the area from the right inferior mandibular aspect and upper cervical area extending from the anterior third of the inferior ramus of the mandible posteriorly to involve the tip of the ear lobe and inferiorly to the mid-third of the sternomastoid muscle. It extended full thickness through the fat and was very well demarcated (Fig. 2). After debridement and excision of the eschar the lesion cleaned up very nicely and the resulting ulcer was grafted three weeks after admission. Subsequently the scarred area has contracted markedly to leave a relatively very small residual defect (Fig. 3).

DISCUSSION

This case report combines an old clinical pres- entation of necrotizing fasciitis as described by Weinberger 6 and earlier by Meleney, 7'8 with a contemporary problem--GBS disease. A similar presentation for GBS has been reported. 9

Necrotizing fasciitis is an unusual disease and occurs most often in adults. Minimum trauma, seemingly insignificant, may precede the devel- opment of this devastating infection. The process then progresses to vesicles on an erythematous base--a stage not seen in our infant but seen in a case reported by Ramamurthy. 9 At this point

From the Greenville Hospital System, Greenville, S.C. Address reprint requests to David H. Wells, M.D., Green-

ville Hospital System, 70l Grove Road, Greenville, S.C. 29605.

�9 1980 by Grune & Stratton, Inc. 0022-3468/80/1505~02t $01.00/0

Journal of Pediatric Surgery, Vol. 15, No. 5 (October), 1980 683

684 BOMAR, FERLAUTO, AND WELLS

Fig. 1

Fig. 2

signs of severe systemic toxicity appear. Charac- teristic is the rapid and widespread superficial fascial necrosis, ischemia, demarcation, and septic infarction of the overlying skin with subse- quent sloughing of large areas of skin.

Hemolytic group A Streptococcus pyogenes and Staphylococcus aureus are most often the primary agents. Meleney has described an occa- sional association with a synergistic gram-nega- tive bacteria. 7'8 The disease in this baby was associated with hemolytic Group ~ streptoccal infection. Other terms used to describe this clini- cal picture are gangrenous erysipelas, necrotiz- ing erysipelas, hospital gangrene, hemolytic streptococcal gangrene and progressive synergis- tic gangrene. 7"8 The presentation in our patient is similar to that described by Weinberger. 6 Both infants were well on discharge from the hospital and then presented with increasing lethargy,

Fig. 3

pallor, respiratory distress, leukopenia, and skin lesions. We would like to emphasize the extreme rapidity with which the process spreads, both locally and systemically and the importance of prompt recognition plus vigorous local and supportive therapy. A penicillin effective against both penicillin sensitive and penicillin resistant staphylococcus combined with an aminoglyco- side to cover possible Gram-negative organisms should be started after appropriate cultures. The specific antibiotic can then be continued once the organism is identified.

Our baby responded promptly to antibiotics and supportive therapy and because of the unusual location of the lesion and early demar- cation, it was felt that by close observation in the absence of any evidence of deterioration that extensive excision of otherwise viable tissue could be avoided. Immediate wide debridement would have been carried out had the process appeared unchanged or progressive. It must be remembered that if earlier removal of necrotic tissue is necessary that the losses of fluid and protein must be replaced similar to that of a full-thickness burn of similar extent.

Skin homografts may be attempted once the eschar has contracted and may result i n the need of a much smaller graft and a more aesthetic result. However, in our patient comparing the widespread area initially involved, a remarkably small residual cosmetic effect is quite gratifying. This scar may be cosmetically refined at a later date.

REFERENCES

1. McCracken GH Jr.: Editorial comment. J Pediatr /3 streptococcal neonatal and infant infections. J Pediatr 89:203, 1976 82:707, 1973

2. Franciosi RA, Knostman JO, Zimmerman RA: Group 3. Howard JB, McCracken GH: The spectrum of group

GROUP B STREPTOCOCCAL INFECTION 685

streptococcal infection in infancy. Am J Dis Child 128:815, 1974

4. Howard JB, McCracken GH: Clinical spectrum of neonatal group ~ disease. Pediatr Res 8:426, 1974

5. Hutto H J, Ayoub EB: Strepococcal osteomyelitis and arthritis in a neonate. Am J Dis Child 129:1449, 1975

6. Weinberger M, Hayes RE, Morse TS: Necrotizing fascititis in a neonate. Am J Dis Child 123:591, 1972

7. Meleney FL: Hemolytic streptococcal gangrene. Arch Surg 9:317, 1924

8. Meleney FL: Hemolytic strep gangrene. JAMA 92:2009, 1929