Scandinavian Journal of Infectious Diseases
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Neonatal Osteomyelitis Caused by Group B Streptococci Eivind Ragnhildstveit & Leiv Ose To cite this article: Eivind Ragnhildstveit & Leiv Ose (1976) Neonatal Osteomyelitis Caused by Group B Streptococci, Scandinavian Journal of Infectious Diseases, 8:3, 219-221, DOI: 10.3109/ inf.1976.8.issue-3.20 To link to this article: http://dx.doi.org/10.3109/inf.1976.8.issue-3.20
Published online: 02 Jan 2015.
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Citing articles: 1 View citing articles
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Date: 17 March 2016, At: 01:15
Scand J Infect Dis 8: 219-221, 1976
Case Report
Neonatal Osteomyelitis Caused by Group B Streptococci EIVIND RAGNHILDSTVEIT and LEIV OSE
Downloaded by [ECU Libraries] at 01:15 17 March 2016
From the Department of Microbiology, the Gade Insiitute, and the Department of Pediatrics, University of Bergen, Bergen, Norway
ABSTRACT. A 3-week-old infant with a group B streptococcal osteomyelitis is described. On admission swelling and fluctuation were combined with local erythema in the right ankle joint region. Group B streptococci, type Ib, were isolated both from blood and from the local focus in the ankle. The diagnosis was further confirmed by X-ray examination showing a lytic lesion in the talus. The child was successfully treated with penicillin, initially in combination with kanamycin.
INTRODUCTION Recent reports have drawn attention to group B P-hemolytic streptococci, Streptococcus agalactiae, as a common cause of serious neonatal infection, mostly septicemia and meningitis (2, 5, 6, 8-1 1). Complications in the perinatal period such as abortions, perinatal death and prematurity have also been associated with infections with this organism (1 1). This report describes a 3-week-old child with a group B streptococcal osteomyelitis. There are very few such reports previously.
CASE REPORT Clinical history A 3-week-old boy presented tenderness, swelling and local erythema in the right ankle joint region. Local heat and fluctuation were also present without obvious skin lesion. He was born on November 2, 1973, after a normal, full-time pregnancy, birth weight 3 810 g, no complications having occurred during delivery and puerperium. There was no evidence of clinical illness or trauma in the neonatal period. He was breast-fed. Immediate family members and close contacts had no sign of infection. Prior to admission the patient had spared his right leg. Touching this leg was obviously painful and provoked crying. There were no other clinical signs of systemic illness. On admission the rectal temperature was 37.4"C, WBC 1 I 50a/pl with 39 % polymorphonuclear leukocytes including 3 % with band forms, and ESR 52 mm. The antistaphylolysin and antistreptolysin reactions showed no increase in titre within 2 weeks. A blood culture drawn prior to treatment on the day of admission revealed pure culture of P-hemolytic strepto-
cocci group B. The region of fluctuation on the right ankle was punctured. Culture of the aspirate also showed pure growth of group B streptococci. Both strains belonged to Lancefields type Ib. The isolated strains were sensitive to benzylpenicillin, ampicillin, cephalothin and lincomycin, fairly sensitive to sulphaisodimidine and slightly sensitive to gentamicin and kanamycin. X-ray of the right ankle revealed a sharply lytic lesion in the talus with a diameter of about 4 mm. There was also soft-tissue swelling adjacent to the involved bone and of the ankle joint. Follow-up X-rays showed regression and ultimately healing. No other destructive foci were seen on X-ray examination. We were not able to demonstrate group B streptococci in a vaginal smear or in breast milk from the mother 5 weeks after delivery. The patient was initially treated with a combination of kanamycin and benzylpenicillin. After one week kanamycin was stopped and penicillin was continued for 6 weeks. The boy made an uneventful recovery, and reexamination at the age of 14 months revealed no clinical or radiological evidence of osteomyelitis. There was normal function of the extremity and no sign of local deformity. Bacteriology The isolated strains were identified as group B streptococci according to the CAMP test (4), the ability to hydrolyse sodium hippurate (I), and serologically by aid of a capillary precipitin reaction using autoclaved antigen and specific group B antiserum (16). Classification of the strains as Lancefields type Ib was done at the Norwegian Defence Microbiological Laboratory, Oslo.
DISCUSSION Barton et al. (5) found group B streptococci to be the most common cause of meningitis due to grampositive organisms during the first 3 months of life, Scand J Infect Dis 8
Downloaded by [ECU Libraries] at 01:15 17 March 2016
220
E. Ragnhildstveit and L . Ose
ranking second only to Escherichia coli as a cause of neonatal meningitis. Eickhoff et al. (9) found that group B streptococci accounted for more cases of neonatal sepsis than any other single organism. These observations fit well with those reported from the Stockholm area, where group B streptococci were responsible for about one quarter of the serious neonatal infections (6). In adults, some cases of arthritis (8, 13) and a few cases of osteomyelitis (15) among other infections, have been described. Among newborns there are very few such reports. Butter and De Moor (8) described an 8-day-old infant with septic arthritis and Kexel (12) a 2-week-old baby with osteomyelitis in the left acromion. Group B streptococci were isolated both from the children and from the vagina of their mothers. We have found no other report in the literature of neonatal osteomyelitis caused by group B streptococci. In cases of neonatal osteomyelitis, delivery is often complicated or there may be an antecedent infection such as omphalitis, respiratory infection, or, most commonly, a skin lesion (17). In our case we found no such predisposing conditions. Recent studies indicate two different types of group B infection according to “early” or ‘‘late’’ onset of the disease in the neonatal period (2,3, 10). The “early-onset’’ type commences within hours or days of a complicated delivery and is often characterized by septicemia, meningitis and respiratory distress (2, 3, 10). The “late-onset” type of infection, which occurs in infants of more than 10 days of age, is most frequently a meningitis, has a lower mortality rate and is almost exclusively caused by type I11 strains. Type 111 is, however, called the “meningitic type” because it is the most frequently isolated type from both early- and lateonset meningitis (2). The favourable outcome in our case fits well with the “late-onset’’ type of infection. Type Ib is not a typical meningitic type. Group B streptococci are reported to be part of the normal flora of the genital tract in 5-18% of pregnant women (7, 8, 10, l l ) , and in the “earlyonset” type of infection it is believed that the newborn is infected through ruptured maternal membranes or while passing through the birth-canal (3, 9-1 I ) . The epidemiology of “late-onset’’ infection is not so clear (2, 3, 10). There are different opinions concerning the risk of group B streptococcal infection in neonates born to mothers who are carriers of this organism (6, 8, 10, I I ) , and the Sccrnd J Iflfect Dis 8
question of vaginal culture and treatment of the carrier immediately prior to delivery has been raised (6, 11). Group B streptococci have been called “the new challenge in neonatal infections” (14) and “a serious threat to the neonate” (18) and in addition to meningitis, septicemia, endocarditis and respiratory distress, we may now include osteomyelitis as a serious infection caused by this organism. ACKNOWLEDGEMENT We would like to thank Rangdi Holth Haug, V.M.D., Norwegian Defence Microbiological Laboratory, who kindly performed the serotyping of the streptococci.
REFERENCES 1. Ayers, S. H. & Rupp, P.: Differentiation of hemolytic
2. 3.
4. 5.
6. 7.
8.
9.
10.
11.
12. 13.
streptococci from human and bovine sources by the hydrolysis of sodium hippurate. J Infect Dis 30: 388, 1922. Baker, C. J. & Barrett, F. F.: Group B streptococcal infections in infants. JAMA 230: 1158, 1974. Baker, C. J., Barrett, F. F., Gordon, R. C. & Yow, M. D.: Suppurative meningitis due to streptococci of Lancefield group B: A study of 33 infants. J Pediatr 82: 724, 1973. Barnum, D. A . : The use of the CAMP test for the rapid identification of Streptococcus agalactiae. Report of the Ontario Veterinary College, p. 120, 1950. Barton, L . L., Feigin, R. D. & Lins, R.: Group B beta hemolytic streptococcal meningitis in infants. J Pediatr 82: 719, 1973. Bergqvist, G., Hurvell, B., Malmborg, A.-S., Rylander, M. & Tunell, R.: Neonatal infections caused by group B streptococci. Scand .IInfect Dis 3: 157, 1971. Bevanger, L.: Carrier rate of group B streptococci with relevance to neonatal infections. Infection 2: 123, 1974. Butter, M. N. V. & de Moor, C. E.: Streptococcus agalactiae as a cause of meningitis in the newborn, and of bacteraemia in adults. Antonie van Leeuwenhoek 33: 439, 1967. Eickhoff, T. C., Klein, J. O., Daly, A. K., Ingall, D. & Finland, M.: Neonatal sepsis and other infections due to group B beta-hemolytic streptococci. N Engl J Med 271: 1221, 1964. Franciosi, R. A., Knostman, J. A. & Zimmerman, R. A.: Group B streptococcal neonatal and infant infections. J Pediatr 82: 707, 1973. Hood, M., Janney, A. & Darneron, G.: Beta hemolytic streptococcus group B associated with problems of the perinatal period. Am J Obstet Gynecol 82:809, 1961. Kexel, G.: Uber das Vorkommen der B-Streptokokken beim Menschen. Z Hyg Infektkrank 151: 336, 1965. Mannik, M., Baringer, J. R. & Stokes, J.: Infections
Osteomyelitis caused by group B streptococci
14. 15. 16. 17. 18.
221
due to group B beta-hemolytic streptococci. N Engl J Med 266: 910, 1962. McCracken, G. H.: Group B streptococci: The new challenge in neonatal infections. J Pediatr 82: 703, 1973. Rantz, L. A. & Kirby, W. M. M.: Hemolytic streptococcus bacteremia. N Engl J Med 227: 730, 1942. Rantz, L. A. & Randall, E.: Use of autoclaved extracts of hemolytic streptococci for serological grouping. Stanf Med Bull 13: 290, 1955. Thornson, J. & Lewis, I. C.: Osteomyelitis in the newborn. Arch Dis Child 25: 273, 1950. Yow, M.: Group B streptococci: A serious threat to the neonate. JAMA 230: 1177, 1974.
Downloaded by [ECU Libraries] at 01:15 17 March 2016
Address for reprints:
E. Ragnhildstveit, M . D . , Department of Microbiology, MFH-bygget, Haukeland Sykehus, N-5016 Bergen, Norway
Scand J lnfecf Dis 8
ISSN: 0036-5548 (Print) 1651-1980 (Online) Journal homepage: http://www.tandfonline.com/loi/infd19
Neonatal Osteomyelitis Caused by Group B Streptococci Eivind Ragnhildstveit & Leiv Ose To cite this article: Eivind Ragnhildstveit & Leiv Ose (1976) Neonatal Osteomyelitis Caused by Group B Streptococci, Scandinavian Journal of Infectious Diseases, 8:3, 219-221, DOI: 10.3109/ inf.1976.8.issue-3.20 To link to this article: http://dx.doi.org/10.3109/inf.1976.8.issue-3.20
Published online: 02 Jan 2015.
Submit your article to this journal
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=infd19 Download by: [ECU Libraries]
Date: 17 March 2016, At: 01:15
Scand J Infect Dis 8: 219-221, 1976
Case Report
Neonatal Osteomyelitis Caused by Group B Streptococci EIVIND RAGNHILDSTVEIT and LEIV OSE
Downloaded by [ECU Libraries] at 01:15 17 March 2016
From the Department of Microbiology, the Gade Insiitute, and the Department of Pediatrics, University of Bergen, Bergen, Norway
ABSTRACT. A 3-week-old infant with a group B streptococcal osteomyelitis is described. On admission swelling and fluctuation were combined with local erythema in the right ankle joint region. Group B streptococci, type Ib, were isolated both from blood and from the local focus in the ankle. The diagnosis was further confirmed by X-ray examination showing a lytic lesion in the talus. The child was successfully treated with penicillin, initially in combination with kanamycin.
INTRODUCTION Recent reports have drawn attention to group B P-hemolytic streptococci, Streptococcus agalactiae, as a common cause of serious neonatal infection, mostly septicemia and meningitis (2, 5, 6, 8-1 1). Complications in the perinatal period such as abortions, perinatal death and prematurity have also been associated with infections with this organism (1 1). This report describes a 3-week-old child with a group B streptococcal osteomyelitis. There are very few such reports previously.
CASE REPORT Clinical history A 3-week-old boy presented tenderness, swelling and local erythema in the right ankle joint region. Local heat and fluctuation were also present without obvious skin lesion. He was born on November 2, 1973, after a normal, full-time pregnancy, birth weight 3 810 g, no complications having occurred during delivery and puerperium. There was no evidence of clinical illness or trauma in the neonatal period. He was breast-fed. Immediate family members and close contacts had no sign of infection. Prior to admission the patient had spared his right leg. Touching this leg was obviously painful and provoked crying. There were no other clinical signs of systemic illness. On admission the rectal temperature was 37.4"C, WBC 1 I 50a/pl with 39 % polymorphonuclear leukocytes including 3 % with band forms, and ESR 52 mm. The antistaphylolysin and antistreptolysin reactions showed no increase in titre within 2 weeks. A blood culture drawn prior to treatment on the day of admission revealed pure culture of P-hemolytic strepto-
cocci group B. The region of fluctuation on the right ankle was punctured. Culture of the aspirate also showed pure growth of group B streptococci. Both strains belonged to Lancefields type Ib. The isolated strains were sensitive to benzylpenicillin, ampicillin, cephalothin and lincomycin, fairly sensitive to sulphaisodimidine and slightly sensitive to gentamicin and kanamycin. X-ray of the right ankle revealed a sharply lytic lesion in the talus with a diameter of about 4 mm. There was also soft-tissue swelling adjacent to the involved bone and of the ankle joint. Follow-up X-rays showed regression and ultimately healing. No other destructive foci were seen on X-ray examination. We were not able to demonstrate group B streptococci in a vaginal smear or in breast milk from the mother 5 weeks after delivery. The patient was initially treated with a combination of kanamycin and benzylpenicillin. After one week kanamycin was stopped and penicillin was continued for 6 weeks. The boy made an uneventful recovery, and reexamination at the age of 14 months revealed no clinical or radiological evidence of osteomyelitis. There was normal function of the extremity and no sign of local deformity. Bacteriology The isolated strains were identified as group B streptococci according to the CAMP test (4), the ability to hydrolyse sodium hippurate (I), and serologically by aid of a capillary precipitin reaction using autoclaved antigen and specific group B antiserum (16). Classification of the strains as Lancefields type Ib was done at the Norwegian Defence Microbiological Laboratory, Oslo.
DISCUSSION Barton et al. (5) found group B streptococci to be the most common cause of meningitis due to grampositive organisms during the first 3 months of life, Scand J Infect Dis 8
Downloaded by [ECU Libraries] at 01:15 17 March 2016
220
E. Ragnhildstveit and L . Ose
ranking second only to Escherichia coli as a cause of neonatal meningitis. Eickhoff et al. (9) found that group B streptococci accounted for more cases of neonatal sepsis than any other single organism. These observations fit well with those reported from the Stockholm area, where group B streptococci were responsible for about one quarter of the serious neonatal infections (6). In adults, some cases of arthritis (8, 13) and a few cases of osteomyelitis (15) among other infections, have been described. Among newborns there are very few such reports. Butter and De Moor (8) described an 8-day-old infant with septic arthritis and Kexel (12) a 2-week-old baby with osteomyelitis in the left acromion. Group B streptococci were isolated both from the children and from the vagina of their mothers. We have found no other report in the literature of neonatal osteomyelitis caused by group B streptococci. In cases of neonatal osteomyelitis, delivery is often complicated or there may be an antecedent infection such as omphalitis, respiratory infection, or, most commonly, a skin lesion (17). In our case we found no such predisposing conditions. Recent studies indicate two different types of group B infection according to “early” or ‘‘late’’ onset of the disease in the neonatal period (2,3, 10). The “early-onset’’ type commences within hours or days of a complicated delivery and is often characterized by septicemia, meningitis and respiratory distress (2, 3, 10). The “late-onset” type of infection, which occurs in infants of more than 10 days of age, is most frequently a meningitis, has a lower mortality rate and is almost exclusively caused by type I11 strains. Type 111 is, however, called the “meningitic type” because it is the most frequently isolated type from both early- and lateonset meningitis (2). The favourable outcome in our case fits well with the “late-onset’’ type of infection. Type Ib is not a typical meningitic type. Group B streptococci are reported to be part of the normal flora of the genital tract in 5-18% of pregnant women (7, 8, 10, l l ) , and in the “earlyonset” type of infection it is believed that the newborn is infected through ruptured maternal membranes or while passing through the birth-canal (3, 9-1 I ) . The epidemiology of “late-onset’’ infection is not so clear (2, 3, 10). There are different opinions concerning the risk of group B streptococcal infection in neonates born to mothers who are carriers of this organism (6, 8, 10, I I ) , and the Sccrnd J Iflfect Dis 8
question of vaginal culture and treatment of the carrier immediately prior to delivery has been raised (6, 11). Group B streptococci have been called “the new challenge in neonatal infections” (14) and “a serious threat to the neonate” (18) and in addition to meningitis, septicemia, endocarditis and respiratory distress, we may now include osteomyelitis as a serious infection caused by this organism. ACKNOWLEDGEMENT We would like to thank Rangdi Holth Haug, V.M.D., Norwegian Defence Microbiological Laboratory, who kindly performed the serotyping of the streptococci.
REFERENCES 1. Ayers, S. H. & Rupp, P.: Differentiation of hemolytic
2. 3.
4. 5.
6. 7.
8.
9.
10.
11.
12. 13.
streptococci from human and bovine sources by the hydrolysis of sodium hippurate. J Infect Dis 30: 388, 1922. Baker, C. J. & Barrett, F. F.: Group B streptococcal infections in infants. JAMA 230: 1158, 1974. Baker, C. J., Barrett, F. F., Gordon, R. C. & Yow, M. D.: Suppurative meningitis due to streptococci of Lancefield group B: A study of 33 infants. J Pediatr 82: 724, 1973. Barnum, D. A . : The use of the CAMP test for the rapid identification of Streptococcus agalactiae. Report of the Ontario Veterinary College, p. 120, 1950. Barton, L . L., Feigin, R. D. & Lins, R.: Group B beta hemolytic streptococcal meningitis in infants. J Pediatr 82: 719, 1973. Bergqvist, G., Hurvell, B., Malmborg, A.-S., Rylander, M. & Tunell, R.: Neonatal infections caused by group B streptococci. Scand .IInfect Dis 3: 157, 1971. Bevanger, L.: Carrier rate of group B streptococci with relevance to neonatal infections. Infection 2: 123, 1974. Butter, M. N. V. & de Moor, C. E.: Streptococcus agalactiae as a cause of meningitis in the newborn, and of bacteraemia in adults. Antonie van Leeuwenhoek 33: 439, 1967. Eickhoff, T. C., Klein, J. O., Daly, A. K., Ingall, D. & Finland, M.: Neonatal sepsis and other infections due to group B beta-hemolytic streptococci. N Engl J Med 271: 1221, 1964. Franciosi, R. A., Knostman, J. A. & Zimmerman, R. A.: Group B streptococcal neonatal and infant infections. J Pediatr 82: 707, 1973. Hood, M., Janney, A. & Darneron, G.: Beta hemolytic streptococcus group B associated with problems of the perinatal period. Am J Obstet Gynecol 82:809, 1961. Kexel, G.: Uber das Vorkommen der B-Streptokokken beim Menschen. Z Hyg Infektkrank 151: 336, 1965. Mannik, M., Baringer, J. R. & Stokes, J.: Infections
Osteomyelitis caused by group B streptococci
14. 15. 16. 17. 18.
221
due to group B beta-hemolytic streptococci. N Engl J Med 266: 910, 1962. McCracken, G. H.: Group B streptococci: The new challenge in neonatal infections. J Pediatr 82: 703, 1973. Rantz, L. A. & Kirby, W. M. M.: Hemolytic streptococcus bacteremia. N Engl J Med 227: 730, 1942. Rantz, L. A. & Randall, E.: Use of autoclaved extracts of hemolytic streptococci for serological grouping. Stanf Med Bull 13: 290, 1955. Thornson, J. & Lewis, I. C.: Osteomyelitis in the newborn. Arch Dis Child 25: 273, 1950. Yow, M.: Group B streptococci: A serious threat to the neonate. JAMA 230: 1177, 1974.
Downloaded by [ECU Libraries] at 01:15 17 March 2016
Address for reprints:
E. Ragnhildstveit, M . D . , Department of Microbiology, MFH-bygget, Haukeland Sykehus, N-5016 Bergen, Norway
Scand J lnfecf Dis 8
