Acute Bacterial Meningitis and Systemic Abscesses due to...

Case ReportAcute Bacterial Meningitis and Systemic Abscessesdue to Streptococcus dysgalactiae subsp equisimilis Infection

M Jourani1 T Duprez2 V Roelants3 H Rodriguez-Villalobos4 and P Hantson1

1Department of Intensive Care Cliniques St-Luc Universite Catholique de Louvain Brussels Belgium2Department of Radiology Neuroradiology Division Cliniques St-Luc Universite Catholique de Louvain Brussels Belgium3Department of Nuclear Medicine Cliniques St-Luc Universite Catholique de Louvain Brussels Belgium4Laboratory of Microbiology Cliniques St-Luc Universite Catholique de Louvain Brussels Belgium

Correspondence should be addressed to P Hantson philippehantsonuclouvainbe

Received 20 February 2017 Accepted 11 April 2017 Published 23 April 2017

Academic Editor Raul Colodner

Copyright copy 2017 M Jourani et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Disseminated abscesses due to group G 120573-hemolytic Streptococcus dysgalactiae were observed in a 57-year-old cirrhotic patientwith the skin being the putative way of entry for the pathogen S dysgalactiae is a rare agent in human infections responsiblefor acute pyogenic meningitis The mortality rate associated with S dysgalactiae bacteraemia and meningitis may be as high as50 particularly in the presence of endocarditis or brain abscesses In our patient main sites of infections were meningitis andventriculitis spondylodiscitis septic arthritis and soft-tissue infections In contrast no endocarditis was evidenced Cirrhosis-related immune suppressionwas considered as a pathophysiological cofactor for the condition Fortunately clinical status improvedafter long-term (3 months) antimicrobial therapy

1 Introduction

Meningitis due to Streptococcus dysgalactiae has been repor-ted in a very restricted number of adult or pediatric casesusually with a mild clinical course [1ndash7] It is usually thoughtthat streptococcal meningitis is acquired via transient colo-nization of the nasopharynx followed by bacteraemia andsubsequent invasion of the central nervous system (CNS)Although invasive infection (including shock renal andliver involvement and soft-tissue necrosis but not menin-gitis) caused by Japanese strains of S dysgalactiae has beenreported S dysgalactiae usually carries a low pathogenicpotential [8] We describe a case of S dysgalactiae bacterae-mia complicated bymeningitis and disseminated abscesses ina cirrhotic patient with favorable outcome

2 Case Report

A 57-year-old man was found lying on the floor of hisroom He had a medical history of heavy chronic ethanolconsumption (more than 10 unitsday for 30 years) but never

underwent hepatic investigations More than 10 years ago hehad had prosthetic replacement of the right knee He had alsoreceived dental care more than twomonths before symptomsonset A few weeks before hospital admission he had a trau-matic fracture of the right calcaneus treated by plaster castimmobilization

At admission to Emergency Department he presentedwith a left-sided hemiparesis dysarthria and confusion Gla-sgow coma scale (GCS) score was calculated at 1315 (E4 V3M6) There was a mild meningeal irritation The body tem-perature was 367∘C and blood pressure was 12566mmHgExamination of the pharynx was unremarkable After castremoval a cellulitis of the right leg was diagnosed togetherwith a thrombosis of the right posterior tibial and peronealveins Antimicrobial treatment was immediately initiatedwith intravenous amoxicillin-clavulanic acid (1 g every 6 h)Both knees were swollen erythematous and painful as wellas both elbows and multifocal septic arthritis was suspected

Laboratory investigations showed a C-reactive protein(CRP) at 333mgdL (normal valuelt 5mgL) andwhite bloodcell count of 19850 cellsmm3 (951 granulocytes) Other

HindawiCase Reports in Infectious DiseasesVolume 2017 Article ID 8645859 4 pageshttpsdoiorg10115520178645859

2 Case Reports in Infectious Diseases

June 1st

(a)

June 1st

(b)

June 21st

(c)

June 21st

(d)

Figure 1 (a-b) Admission brain MRI (c-d) follow-up brain MRI three weeks later (a) Contrast-enhanced (CE) axial transverse fluid-attenuated inversion-recovery (FLAIR) view at admission showing diffuse abnormal enhancement of ependyma (white arrow) and bilateralfluid-fluid level at trigonal areas of lateral ventricles (black arrow) (b) Admission diffusion-weighted (DW) axial transverse view at admissionat similar slice location as in (a) showing high signal intensity within declive sediment of the fluid-fluid level featuring pus with free waterdiffusivity restriction (dotted arrows) (c) CE FLAIR view in similar slice location as in (a) three weeks later showing complete subsidenceof ependymal contrast-enhancement (white arrow) and disappearance of the fluid-fluid levels (black arrow) Only persistent enhancedbrightness of ependymal lining was seen (d) DW image in similar slice location as in (b) showing only minimal purulent residue withinleft ventricular trigone (dotted arrow)

standard laboratory findings were within normal rangeexcept for an international normalized ratio (INR) at 237 andserum CK level at 1569 IUl (normal value lt 200) Microsco-pic hematuria and mild proteinuria were noted at urineanalysis The brain computed tomography (CT) scan did notreveal any specific lesion as well as fundoscopic examina-tion A lumbar puncture was performed and cerebrospinalfluid (CSF) examination showed white blood cells count of

1127 cellsmm3 (64 granulocytes) glucose not detectableand protein of 1848mgdL The CSF Gram-staining revealedthe presence of rare white blood cells but no organismTwo sets of blood cultures were positive for S dysgalactiaewhile CSF culture remained sterile after seven days ofincubation including enriched culture media S dysgalactiaewas not isolated from the skin nose and throat swapsBlood cultures became sterile 24 hours after the start of

Case Reports in Infectious Diseases 3

(a) (b)

Figure 2 (a) MIP (maximum intensity projection) of FDG PET showing multiple areas of hypermetabolic activity corresponding todisseminated foci of infection and (b) transaxial views of CT fused FDG PET-CT and FDG PET images representative of several foci ofinfection disseminated in joints soft tissues and lumbar column (arrows)

antimicrobial therapy The universal PCR 16S rRNA genesequencing (qPCR16S) using SQ1-S (50-AgAgTTTgATCC-TggCTCAg-30) SQ1-AS (50-AAggAGGTgATCCARCCg-CA-30) SQ2-AS (51015840-gggTTgCgCTCgTTG-30) and SQ3-AS 50-TCTACgCATTTCACCgCTAC-3 primers (96GA3730XL Applied BiosystemUSA) applied directly to CSF sampleswas negative There was no evidence of endocarditis at echo-cardiography

Surgical treatment was required for the right prostheticknee and culture of purulent material yielded S dysgalactiaesubsp equisimilis Aerobic and anaerobic cultures of purulentmaterial from the left knee and both elbows remained sterileafter seven days of incubation

The search for metastatic foci included total body com-puted tomography (CT) scan examination spine and brainmagnetic resonance imaging (MRI) and total body flu-orodeoxyglucose positron emission tomographycomputedtomography (FDG PET-CT)

Brainmagnetic resonance imaging (MRI) was performedon admission and three weeks later and was consistentwith acute ventriculitis without evidence of brain abscesses(Figure 1)

FDG PET-CT revealed multiple areas of hypermetabolicactivity in joints soft tissues and spine corresponding todisseminated infection (Figure 2) Mainly L2-L3 interver-tebral space sternoclavicular joints knees left hip elbowsleft shoulder left deltoid muscle right subscapularis muscleleft obturator internus muscle and gluteal muscles wereinvolvedNo abnormalmetabolic activity was observed in thecardiac area and no abnormal FDG uptake leading to cancersuspicion was observed No abnormal metabolic activity wasobserved in the cardiac area and no abnormal FDG uptakeleading to cancer suspicion was observed

In addition spinal MRI demonstrated diffuse and severeintrathecal inflammatory changes together with a L2-L3spondylodiscitis with only moderate involvement of adjacentepidural spaces (not shown)

On day 3 antimicrobial therapy was switched to intra-venous ceftriaxone (2 gevery 12 h) and ampicillin (1 gevery6 h) and thereafter to rifampicin 600mgday Hepatic fibro-sis stage F4 was diagnosed by ultrasound elastography(FibroScan) At 3-month follow-up the patient had a com-plete functional recovery normalized inflammatory markersand antimicrobial therapy was thereafter discontinued

3 Discussion

Streptococcus dysgalactiae subsp equisimilis is a human-pathogenic betahaemolytic pyogenic Streptococcus harboringthe Lancefield group G C or L antigens Pathogenic strainsharbor virulence genes similar to virulence genes to S pyo-genes and have been associated with upper respiratory tractinfection (pharyngitis mainly in children) skin and soft-tissue infections and invasive infectionsWhile Streptococcusdysgalactiae subsp equisimilismay belong to the commensaloropharyngeal flora invasive infections may be caused byperson-to-person transmission [9] An increasing number ofpatients with severe invasive S dysgalactiae infection havebeen observed in Japanduring the early 2000s [8]The clinicalcourse included shock and a varying number of patientswith renal impairment disseminated intravascular coagula-tion liver involvement adult respiratory distress syndrome(ARDS) generalized erythematous macular rash and soft-tissue necrosis The strains did not seem to expand clonallybut they were carrying specific genes-related virulence (scpAska slo and sag genes) People developing a severe infectionwith this organism were likely to suffer cancer in 21ndash65of cases or to be immunocompromised by diabetes mellituscirrhosis or alcohol abuse [10ndash14]

Acute bacterial meningitis could result either by hemato-genous spreading to the CNS or from a local extension to thesubarachnoid spaces [15] It seems important to exclude thepresence of cerebral abscesses when meningitis is diagnosed


and to look for endocarditis which is present inmost cases ofgroup G StreptococcusmeningitisThemortality rate associa-ted with group G Streptococcus meningitis is not preciselyestablished but could be as high as 50 In the herebyreported case endocarditis could be ruled out by repeatedlynegative cardiac echography In the case reported here CSFculture and universal 16S rRNA PCR were negative Becauseof low sensitivity and false positive and negative results theqPCR16S test applied directly in samples should be inter-preted with caution and needs the use in parallel of micro-biological cultures However the final diagnosis of bacterialmeningitis which is generally based on CSF microbiologicalcultures can be inconclusive in 20 of cases of patients withcommunity bacterial acquired meningitis rising to less than50 of cases if patients have received prior antimicrobialtherapy In the present observation hematogenous origin ofmeningeal infection was considered more likely than focalcontamination from epidural infection

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

References

[1] C Luyx D Vanpee Y Glupczynski C Swine and J-B GilletldquoDelayed diagnosis ofmeningitis caused by120573-haemolytic groupG Streptococcus in an older womanrdquo Journal of EmergencyMedicine vol 21 no 4 pp 393ndash396 2001

[2] J Berenguer I Sampedro E Cercenado J Baraia M Rodrı-guez-Creixems and E Bouza ldquoGroup-C 120573-hemolytic strep-tococcal bacteremiardquo Diagnostic Microbiology and InfectiousDisease vol 15 no 2 pp 151ndash155 1992

[3] L C Mollison and E Donaldson ldquoGroup C streptococcal men-ingitisrdquo The Medical Journal of Australia vol 152 pp 319ndash3201990

[4] S J Chung ldquoMeningitis caused by streptococcus equisimilis(group C)rdquo SouthernMedical Journal vol 75 no 6 p 769 1982

[5] RWaltereit UHerrlingerM Stark and S Borgmann ldquoMenin-gitis in a pregnant woman caused by Streptococcus dysgalactiaesubspecies equisimilisrdquo Polish Journal of Microbiology vol 62no 2 pp 217ndash219 2013

[6] J A Hervas M V Labay G Rul-lan L Aguilar J Gil and PAlomar ldquoNeonatal sepsis and meningitis due to streptococcusequisimilisrdquoThe Pediatric Infectious Disease Journal vol 4 pp694ndash695 1985

[7] R JMQuinn A F Hallett P C Appelbaum and R C CooperldquoMeningitis caused by Streptococcus dysgalactiae in a preterminfantrdquoAmerican Journal of Clinical Pathology vol 70 no 6 pp948ndash950 1978

[8] T Ikebe S Murayama K Saitoh et al ldquoSurviellance of severeinvasive group-G streptococcal infections andmolecular typingof the isolates in Japanrdquo Epidemiology and Infection vol 132 no1 pp 145ndash149 2004

[9] K Sunaoshi S Y Murayama K Adachi et al ldquoMolecularemm genotyping and antibiotic susceptibility of Streptococcusdysgalactiae subsp equisimilis isolated from invasive and non-invasive infectionsrdquo Journal of Medical Microbiology vol 59 no1 pp 82ndash88 2010

[10] C Vartian P I Lerner D M Shlaes and K V GopalakrishnaldquoInfections due to lancefield group G Streptococcirdquo Medicine(Baltimore) vol 64 no 2 pp 75ndash88 1985

[11] C E Liu T N Jang F D Wang L S Wang and C Y LiuldquoInvasive groupG streptococcal infections a review of 37 casesrdquoChung Hua I Hsueh Tsa Chih (Taipei) vol 56 pp 173ndash178 1995

[12] F R Venezio R M Gullberg G O Westenfelder J P Phairand F V Cook ldquoGroup G streptococcal endocarditis andbacteremiardquoTheAmerican Journal of Medicine vol 81 no 1 pp29ndash34 1986

[13] R Auckenthaler P E Hermans and J A Washington ldquoGroupG streptococcal bacteremia clinical study and review of theliteraturerdquo Reviews of Infectious Diseases vol 5 no 2 pp 196ndash204 1983

[14] K L Watsky N Kollisch and P Densen ldquoGroup G Streptococ-cal Bacteremia the clinical experience at Boston universitymedical center and a critical review of the literaturerdquo Archivesof Internal Medicine vol 145 no 1 pp 58ndash61 1985

[15] KMoslashller EHarder Frederiksen JHeughWandall andP Skin-hoslashj ldquoMeningitis caused by streptococci other than Streptococ-cus pneumoniae a retrospective clinical studyrdquo ScandinavianJournal of Infectious Diseases vol 31 no 4 pp 375ndash381 1999

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June 1st

(a)

June 1st

(b)

June 21st

(c)

June 21st

(d)

Figure 1 (a-b) Admission brain MRI (c-d) follow-up brain MRI three weeks later (a) Contrast-enhanced (CE) axial transverse fluid-attenuated inversion-recovery (FLAIR) view at admission showing diffuse abnormal enhancement of ependyma (white arrow) and bilateralfluid-fluid level at trigonal areas of lateral ventricles (black arrow) (b) Admission diffusion-weighted (DW) axial transverse view at admissionat similar slice location as in (a) showing high signal intensity within declive sediment of the fluid-fluid level featuring pus with free waterdiffusivity restriction (dotted arrows) (c) CE FLAIR view in similar slice location as in (a) three weeks later showing complete subsidenceof ependymal contrast-enhancement (white arrow) and disappearance of the fluid-fluid levels (black arrow) Only persistent enhancedbrightness of ependymal lining was seen (d) DW image in similar slice location as in (b) showing only minimal purulent residue withinleft ventricular trigone (dotted arrow)

standard laboratory findings were within normal rangeexcept for an international normalized ratio (INR) at 237 andserum CK level at 1569 IUl (normal value lt 200) Microsco-pic hematuria and mild proteinuria were noted at urineanalysis The brain computed tomography (CT) scan did notreveal any specific lesion as well as fundoscopic examina-tion A lumbar puncture was performed and cerebrospinalfluid (CSF) examination showed white blood cells count of

1127 cellsmm3 (64 granulocytes) glucose not detectableand protein of 1848mgdL The CSF Gram-staining revealedthe presence of rare white blood cells but no organismTwo sets of blood cultures were positive for S dysgalactiaewhile CSF culture remained sterile after seven days ofincubation including enriched culture media S dysgalactiaewas not isolated from the skin nose and throat swapsBlood cultures became sterile 24 hours after the start of


(a) (b)









3 Discussion







References





















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Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)









3 Discussion







References





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




















References





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















Acute Bacterial Meningitis and Systemic Abscesses due to...

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