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Journal of Postgraduate Medicine, Vol. 54, No. 1, January-March, 2008, pp. 64-65 Letter Bacterial endocarditis due to Group C streptococcus Menon T, Nandhakumar B, Jaganathan V, Shanmugasundaram S, Malathy B, Nisha B Department of Microbiology, Dr. A. L. Mudaliar Post Graduate Institute of Basic Medical Sciences, University of Madras, Taramani, Chennai - 600 113 Code Number: jp08028 Sir, Streptococcus dysgalactiae subsp equisimilis (GCSDE) which occurs as normal human flora, is found in approximately 2-6% of cases of pharyngitis but rarely causes serious infections. [1] Endocarditis caused by GCSDE is infrequently reported and it is associated with a high mortality rate. A 35-year-old male with a bicuspid aortic valve, was admitted with fever of one week duration, arthralgia, dyspnea and chest pain. On physical examination, his blood pressure was 160/50 mm Hg, his pulse rate 120 per min and body temperature was 100°F. Pallor, splenomegaly, petechiae and unilateral scrotal swelling with desquamation were also noted. His white blood cell count was 12,400 cells/mm 3 with 86% neutrophils, 10% lymphocytes and 4% eosinophils. The hemoglobin level was 14.0 g/dl, the platelet count was 1,10,000/mm 3 and erythrocyte sedimentation rate was 32 mm for 1 h. The electrocardiogram revealed sinus tachycardia, incomplete left bundle branch block and left ventricular hypertrophy (poor R-wave progression and ST-T interval abnormalities). The transthoracic echocardiogram demonstrated a large vegetation attached to the left ventricle outflow tract, with severe aortic regurgitation, moderate left ventricular dysfunction, dilatation of the left ventricle and mild aortic stenosis. Three samples of blood were drawn for culture after which antibiotic treatment was started which consisted of intravenous regimen of penicillin G (4 x 10 6 IU every 6 h) and gentamicin (80 mg twice daily). Blood cultures processed by standard protocols [2] grew beta hemolytic streptococci which was serogrouped as a Group C streptococcus using specific antisera by latex agglutination tests (Remel Diagnostics Europe). The isolate was identified as Streptococcus dysgalactiae subsp equisimilis using the Rapid ID 32 Strep System (BioMerieux, USA). Antimicrobial susceptibility testing was performed by the Kirby-Bauer disc diffusion method according to CLSI (formerly NCCLS) recommendations. [3] The isolate was found to be susceptible to penicillin G, ampicillin, ceftriaxone. The patient responded well to treatment with penicillin and gentamicin and was afebrile within 72 h after initiation of therapy. Antibiotic treatment was continued for four weeks. The blood cultures were negative when repeated after four weeks. The patient had an uneventful recovery and was discharged from hospital. Streptococcus dysgalactiae subsp equisimilis can colonize the throat, skin and the genitourinary tract. From these sites, the organisms frequently invade soft tissue and other deep structures. Endocarditis due to GCSDE is an infrequent clinical entity and the predisposing conditions are rheumatic heart disease, bicuspid aortic valve, mitral valve prolapse, congenital heart disease (as in this case), calcific aortic stenosis and aortic valve insufficiency. Endocarditis due to Streptococcus dysgalactiae subsp equisimilis infections has been reported in the literature. [4] This patient had a congenital heart disease in the form of a bicuspid aortic valve. However, we were unable to identify the source of infection. Mohanty et al., has reported Group C streptococcal bacteremia in a patient with aplastic anemia without endovascular involvement. [5] To the best of our knowledge, this is the first report of Streptococcus dysgalactiae subsp equisimilis endocarditis from India. References
Copyright 2008 - Journal of Postgraduate Medicine |
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