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Recurrent Streptococcus pyogenes genital infection in a
woman: test and treat the partner!
Emilienne Verkaeren, Loıc Epelboin, Sylvie Epelboin, Nathalie Boddaert,
Florence Brossier, Eric Caumes
To cite this version:
Emilienne Verkaeren, Loıc Epelboin, Sylvie Epelboin, Nathalie Boddaert, Florence Brossier, et al..
Recurrent Streptococcus pyogenes genital infection in a woman: test and treat the partner!.
In-ternational Journal of Infectious Diseases, Elsevier, 2014, 29, pp.37-39. �10.1016/j.ijid.2014.07.026�.
�hal-01328632�
Case
Report
Recurrent
Streptococcus
pyogenes
genital
infection
in
a
woman:
test
and
treat
the
partner!
Emilienne
Verkaeren
a,b,*
,
Loı¨c
Epelboin
a,b,
Sylvie
Epelboin
c,
Nathalie
Boddaert
d,
Florence
Brossier
b,e,
Eric
Caumes
a,ba
AssistancePublique–HoˆpitauxdeParis,InfectiousandTropicalDiseasesDepartment,HoˆpitalPitie´-Salpeˆtrie`re,83boulevarddel’Hoˆpital,75013,Paris, France
b
UPMCUniversite´ Paris6,Paris,France
cAssistancePublique–HoˆpitauxdeParis,Gynaecology,ObstetricsandAssistedReproductiveTechniquesDepartment,HoˆpitalBichat-Claude-Bernard,France d
AssistancePublique–HoˆpitauxdeParis,RadiologyDepartment,HoˆpitalNecker-EnfantsMalades,Paris,France
e
AssistancePublique–HoˆpitauxdeParis,LaboratoryofBacteriology,HoˆpitalPitie´-Salpeˆtrie`re,Paris,France
1. Introduction
Streptococcuspyogenes, or group A beta-haemolytic Strepto-coccus(GAS), isa Gram-positivecoccusassociated witha wide range of infections, mostly skin and soft tissueinfections and throat infections. Genital infections include endometritis and vulvovaginitis, which are rare manifestations of GAS more frequentlyreported inprepubescentgirlsthaninadultwomen. WedescribethecaseofamenopausalwomanwithrecurrentGAS vaginitisrelatedtochroniccarriageinherhusband.
2. Casereport
A64-year-old womanwas admitted forfever and a vaginal discharge. She was married and had given birth twice in her twenties. Ten years earlier she had undergone a right hemi-colectomyforcoloncancerthatwasincompleteremission.She hadpresentedwithendometriosis12years previously,andhad
gonethroughmenopausefor9years,withouthormonaltreatment. Shepresentedtohergynaecologistwitha10-daydurationwhitish vaginaldischarge.Hereportedanormalexaminationandcollected avaginalsampleformicrobiologicalanalysis.
The following day,the woman was hospitalized because of fever and right flank pain. A clinical examination was normal exceptforfever(38.78C)andavaginaldischarge.Bloodsamples showedanormalwhitebloodcellcount(leukocytes6.6109/l). TheC-reactiveproteinlevelwas49mg/l(normal<5mg/l).Urine directexaminationshowedleukocyturia(1.9105/ml).Bloodand urinecultureswerepositiveforawild-typestrainofGAS,aswas the vaginal sample taken before this admission. Abdominal ultrasoundandcomputedtomographyscanswerenormal,except forathickenedwomb.Pelvicmagneticresonanceimaging(MRI) showedanimportantadenomyosis,atypicalforapostmenopausal woman,associatedwiththickeningandinfiltrationoftheuterine horns and round ligaments suggestive of an inflammatory or infectious process. The diagnosis of GAS-related septicaemia complicating pelvic endometritis was considered, although there was no endocavitary or tubal retention. She was given intravenousamoxicillin6g/day,1mg/kg/day.Hercondition and
InternationalJournalofInfectiousDiseases29(2014)37–39
ARTICLE INFO Articlehistory: Received4June2014 Accepted30July2014
CorrespondingEditor:EskildPetersen, Aarhus,Denmark Keywords: Streptococcuspyogenes Vaginitis Bacteraemia Asymptomaticdiseases Antibioticprophylaxis SUMMARY
GroupAStreptococcus(GAS)isawell-knowncauseofvulvovaginitisinprepubescentgirls,butitis rarelydescribedinadultwomen.Wedescribethecaseofa64-year-oldwomanwhopresentedwith endometritisrevealedbyGASbacteraemia,followedbyrecurrentvulvovaginitisduetoawild-type strainofGAS.She relapsedtwicedespiteamoxicillintreatment.Herhusbandwas foundto bean asymptomaticcarrierafterGASwasidentifiedinnasalandrectalswabs.Shewascuredaftereradication ofcarriageinbothherselfandherhusbandwithamoxicillinandrifampin.WhenrecurrentStreptococcus pyogenesgenitalinfectionsoccur,testandtreatthepartner.
ß2014TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/3.0/).
* Correspondingauthor.Tel.:+33142167822.
E-mailaddress:verkaeren_emilienne@yahoo.fr(E.Verkaeren).
ContentslistsavailableatScienceDirect
International
Journal
of
Infectious
Diseases
j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / i j i d
http://dx.doi.org/10.1016/j.ijid.2014.07.026
1201-9712/ß2014TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/3.0/).
the inflammatory biological syndrome improved rapidly after 2daysandshewasdischargedwithoralamoxicillin6g/dayfor 15days.
Twomonthslaterthevaginaldischargerecurredwithoutfever orpainandswabcultureswereagainpositiveforGAS.She was treatedforGASvaginitiswitha12-dayregimenoforalamoxicillin (2g/day,1mg/kg/day),withtheadditionofrifampin300mg/day (5mg/kg/day) for the 2 last days. Four months later the GAS vaginitisrecurredandshewasagaintreatedwithoralamoxicillin. Acolonoscopydidnotrevealanyabnormality.AnewpelvicMRI anda hysteroscopywerenormalandendometrialbiopsieswere negative.
One monthlater, nasaland rectal swabs weretakenfor the patientandherhusband(bothbeingasymptomatic);both were positive for GAS. All of the available samples including blood cultureandvaginalswabscollectedduringthefirstepisodewere senttotheFrenchReferenceCentreforStreptococci. Characteri-zationoftheisolatedstrainsshowedidenticaltypesofGAS,with emm-type 28 subtype 28.0. The emm-types were determined by sequencingthe variable 50 end of the emmgene after PCR amplification,inaccordancewiththerecommendationsoftheUS CentersforDiseaseControlandPrevention(http://www.cdc.gov/ ncidod/biotech/strep/doc.htm). Thus,theywereboth considered asymptomaticgastrointestinaland nasopharyngealGAS carriers andbothreceivedantibioticprophylaxiswithamoxicillin(2g/day) for12daysandoralrifampin(600mg/12h)forthelast2days.No recurrencewasobservedafter2yearsoffollow-up.
3. Discussion
Thismenopausalwomanpresentedwithrecurrentepisodesof genitalGAS infection includingvulvovaginitisand a potentially life-threateningendometritis.Therecurrences disappearedafter eradicationofprovencarriageinthepatientandherhusband.
Although GAS is an established cause of vulvovaginitis in prepubescentgirls,itisrarelydescribedinadultwomen,inwhom itisconsideredanemergingentity.1Indeed,inastudyconducted
in2009,noGASwasisolatedfromcontrolsubjectsparticipatingin cervicalcancerscreening,whereas4.8%of1010patients present-ingwithvulvovaginitiswerepositiveforGAS.2Ithasalsobeen
described in post-partum endometriosis, but rarelyin postme-narchalwomen.3Inadultwomen,suchinfectionscouldbedueto
thesuperficialinfectionofthevaginal wallsfacilitatedby post-menopausalvaginalatrophy.1 GAS vulvovaginitishasalsobeen linkedtochronicdermatologicalconditions,vaginalforeignbody, sexualabuse,andanatomicalabnormalities.4
GASisnotalwayssymptomatic,andthegenitalandrectaltracts werefoundtobecolonizedbyGAS in0.03%of6944womenat 35–37weeksofpregnancyin2000.5Inarecentstudyconducted
among1600pregnantwomenintheUKbySaabetal.6,onlyone
patient (0.06%) was found to be positive for GAS. Concerning theprevalence of asymptomatic pharyngeal GAS carriage, it is quitehigh in children (around 10%),but is generally lower in adults:ina Danishstudy conductedby Hoffmanet al.7, it was
foundtobe2.2%inthegeneralpopulationaged>14years,whileit was10.4%belowthisage.
HandcontactisgenerallyconsideredtheprimaryrouteofGAS transmission,andGASvulvovaginitishasbeenassociatedwitha householdorpersonalhistoryofGAS-relatedskinorrespiratory infection.Inpremenarchalgirlswithvulvovaginitis,41%reporteda familyorpersonalhistoryofdermalorrespiratoryinfectiondueto GAS.However,familialcontaminationhasalsobeenreportedina motherwithGAS-associatedvulvovaginitisandperinealcellulitis andherchildwithGASpharyngitis.
SexualtransmissionofGAShasbeendescribed.Asanexample, aseverecaseofGAS-relatedperitonitisandtoxicshocksyndrome
wasreportedina45-year-oldwomanwithanintrauterinedevice; her husband was found to be an oropharyngeal carrier of anidenticalGASstrain.Similarly,awomanwasdiagnosedwith GAS-related vulvovaginitis and a sore throat after having oral andvaginalsexwithherhusbandwhohadGAS-associatedpenile erosions.
Inourcase,theGASstrainwasthesameinthepatientandher husband–emm-type28subtype28.0.Between2006and2010, thepercentageofthisspecificemm-type28inanykindofinfection intheFrenchnationalreferencecentreincreasedfrom18%to24%. GAShasaparticulartropismforthefemalegenitaltractandalso forthepharyngealandskinsphere,particularlywithemm-type28. Our patient presented two conditions that could have contributedtotherecurrenceandseverityoftheGASinfections. Shehadgonethroughthemenopause,sowaslikelytohavevaginal atrophy in theabsence ofhormonal treatment. She alsohad a history of peritoneal endometriosis associated with significant adenomyosis, atypical for a postmenopausal woman not on hormonaltreatment,facilitatingthedeepinfection.Hermedical historywasrevealedbytheGASbacteraemia,likelyconsecutiveto theGASendometritis.Thisinfectionmaybesevere,asinthecaseof a 57-year-oldwoman who died as a resultof fatal sepsis and disseminatedintravascularcoagulationfollowingGAScervicitis.
However, GAS is not considered a sexually transmitted infection and sexual partners are not initially considered for screening.Inourcase,screeningrevealedthepatient’shusbandto beanasymptomaticcarrierandtheGASreservoirforherrecurrent infections.Suchfindingshavenotbeenlargelyreported.Wefound only onereportof recurrentGAS vulvovaginitisin two women whose husbands were gastrointestinal carriers of GAS, with identicaltypesofGASin eachpartner(emm-type28).Relapses were considered to occur through shedding in bed, and after eradicationofGAScarriagewithrifampin,thesymptomsdidnot relapse.Similarly,asourpatientreportednothavinghadsexual relationsforseveralyears,themostlikelyrouteoftransmission wasthoughttobeindirectthroughhandcontactandsheddingin bed.1 Inadditiontoantibioticprophylaxis,we thusrecommend
washingthebedclothes.
AstherearenoguidelinesconcerningGAScarriage,andasmany antibiotic classes have been tried, the use of rifampin for GAS eradicationwasbasedontheexperienceacquiredwith meningococ-calpharyngealcarriage.1Inourcase,antibioticprophylaxisincluded
rifampinandamoxicillininbothpartnersandthiswasdemonstrated to be efficient in eradicating the GAS pharyngeal carriage. This treatmentdefinitivelystoppedtheGASvaginitisrelapses.
In thecase of recurrent GAS vulvovaginitis we recommend screeningbothsexualpartnersforintestinalandnasopharyngeal carriage and to consider an antibiotic regimen for eradicating the bacteriumand avoiding relapse. Further studies should be conductedtoevaluatetheneedtoscreensexualpartnersinthe caseofafirstepisodeofGASgenitalinfection.
Acknowledgements
The authors would like to thank Professor Anne Bouvet, NationalReferenceCentreforStreptococci,forhelpfuldiscussions. They would also like to thank Dr Pierre Gadonneix for the informationconcerningthepatient’smedicalstory.
Conflict of interest: There is no commercial relationship or potentialconflictofinterestrelatedtothisreport.Nofundingwas received.
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