GROUP B STREPTOCOCCAL EPIGLOTTITIS

Abstract

Epiglottitis is a life-threatening, rapidly progressive infection in children, usually between the ages of 2 and 6 years.1 The most common causative organism is Haemophilus influenzae type b (Hib). Rarer causes include Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus parainfluenzae and group A Streptococcus.1 With the advent of Hib capsular conjugated polysaccharide vaccine, it has been suggested that different agents, which were previously less common causes of epiglottitis, will emerge.2 We report an 11-week-old infant with epiglottitis who had a positive blood culture for group B streptococcus (GBS). Report of a case. An 11-week-old male infant born by normal vaginal delivery was admitted to Sheffield Children's Hospital and given ventilatory support after transfer from a nearby hospital. He had a 3-hour history of sudden onset of acute respiratory distress and coryza for 2 days. The past history included two hospital admissions, one at 7 days of age with a coryzal illness and another at 4 weeks with bronchiolitis. He had been given one dose each of the diphtheria, tetanus, pertussis and Hib vaccines. Examination before intubation revealed sternal and intercostal recession, inspiratory and expiratory stridor and tachypnea of 66 breaths/min. Auscultation of his chest revealed generalized decreased air entry. Blood oxygen saturation in air was 73%. The total white blood cell count was 23.5 × 109/l with a neutrophilia of 18.6 × 109/l. Direct laryngoscopy revealed a red, swollen epiglottis. Intravenous cefotaxime and penicillin G were prescribed. The blood culture yielded a pure growth of group B Streptococcus that was serotyped as Ib/c. Because the organism was susceptible in vitro to penicillin, cefotaxime administration was stopped. Culture from the tip of the epiglottis was negative. The patient received intermittent positive pressure ventilation for 2 days and remained on nasal continuous positive airway pressure for an additional 8 days before extubation. He received intravenous penicillin G for 10 days and was transferred to his original hospital on Day 13 where he made a complete recovery. Discussion. Group B streptococcal infection can cause early onset disease (age <7 days) and late onset disease (>7 days to 12 weeks) as in this case.3, 4 The usual serotype of late onset GBS infection is serotype III.3 Beyond infancy invasive GBS disease is uncommon. In a large retrospective review 18 patients during a 7-year period, including children from 3 months to 18 years old, were described with GBS disease and epiglottitis was not reported.5 In this series serotype III was the most common but other serotypes I/a, Ia/c, Ib/c, II, II/c and V were responsible for bacteremia, septic arthritis, endocarditis, meningitis or ventriculoperitoneal shunt infection. Our patient had serotype Ib/c infection. There had been no perinatal history of note. There are no other published cases of GBS epiglottitis in children. A 3-month-old infant has been reported with a supraglottitis but this did not involve the epiglottis.6 That patient required an endotracheal tube for only 48 hours which may have reflected the lack of involvement of the epiglottis.6 Our patient required airway support for 10 days, which unusual for epiglottitis caused by Hib in which airway support is usually for 2 to 3 days.1 This may have been because of the relative size of the airway but could also have been due to the pathogenicity of the GBS. Group A streptococcal supraglottitis has a longer protracted course requiring prolonged intubation.7 There has been speculation that the organisms isolated from children with epiglottitis will change.2 If organisms other than Hib become a more common cause for epiglottitis it may be possible that the disease characteristics such as the length of ventilatory support required and the type of antimicrobial treatment needed may also change. Acknowledgments. We thank nursing, medical and laboratory staff at Doncaster Royal Infirmary who were involved in the care of the patient and also the Streptococcus and Diphtheria Reference Laboratory, Colindale, London, for serotyping the strain of group B Streptococcus. Nicola Young, M.B., Ch.B.; Adam Finn, M.R.C.P. (UK), Ph.D.; Colin Powell, M.R.C.P. (UK) Department of Medical Microbiology Royal Hallamshire Hospital Sheffield S10 2JF (NY) University Department of Paediatrics The Children's Hospital Sheffield S10 2TH (AF, CP) United Kingdom