Two Cases and A Review of Streptococcus Pyogenes Endocarditis in Children
Two Cases and A Review of Streptococcus Pyogenes Endocarditis in Children
Two Cases and A Review of Streptococcus Pyogenes Endocarditis in Children
CASE REPORT
Open Access
Abstract
Background: Infective endocarditis is a rare diagnosis in pediatrics. Group A beta-hemolytic Streptococcus pyogenes
is known to cause a range of type and severity of infections in childhood. However, S. pyogenes is a rarely described
cause of endocarditis in children. This paper presents two cases of S. pyogenes endocarditis and the largest and
most up-to-date review of cases previously reported in the literature.
Case presentation: Here we describe two pediatric cases of S. pyogenes endocarditis with associated toxic shock.
Case 1 was a previously well Caucasian 6-year-old female who presented with sepsis. Case 2 was an 8-month-old
South Asian female who presented with sepsis and pneumonia. We present a review of the literature since the
beginning of the antibiotic era of this unusual cause of bacterial endocarditis in children.
Conclusion: In addition to the two cases presented here, a total of 13 children have been reported since 1940 with
endocarditis caused by S. pyogenes for which clinical details are available. Although few cases exist, literature review
reveals a high mortality rate (27%) and the majority of patients who recovered had residual morbidities. We
emphasize the importance of considering a diagnosis of endocarditis in cases of S. pyogenes sepsis or toxic shock in
order to ensure early diagnosis and timely treatment, which are necessary for good outcomes. This information is
relevant to both general and subspecialty pediatricians, especially emergency room and infectious disease
physicians.
Keywords: Endocarditis, Streptococcus pyogenes, Group A Streptococcus, Toxic shock
Background
Infective endocarditis (IE) is a rare diagnosis in children.
Group A beta-hemolytic Streptococcus pyogenes can cause
a range of type and severity of infections in childhood including invasive, toxin-mediated, and immune-mediated
disease. However, S. pyogenes is a rarely described cause of
IE in children. The estimated proportion of IE caused by
S. pyogenes in children under age 21 is less than 3% [1]. In
addition to the two cases presented here, a total of 13 children have been reported since 1940 with endocarditis
caused by S. pyogenes for which clinical details are available. Here we describe two cases of IE caused by S. pyogenes in children with associated toxin-mediated disease,
* Correspondence: shaun.morris@sickkids.ca
1
Department of Pediatrics, The Hospital for Sick Children, 555 University
Avenue, M5G 1X8 Toronto, Ontario, Canada
2
Division of Infectious Diseases, The Hospital for Sick Children, Toronto,
Canada
Full list of author information is available at the end of the article
Case presentation
Case 1
2014 Weidman et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
A previously well 8-month-old South Asian female presented to a community hospital with a clinical picture
suggestive of sepsis. She had a 1-week history of fevers
and viral respiratory prodrome and a 2-day history of
lethargy and poor oral intake. On initial presentation,
she had increased work of breathing and chest x-ray
demonstrated a right pleural effusion. She was initially
treated with vancomycin, cefotaxime, and oseltamivir.
On day 2 of hospitalization, she was intubated due to
worsening lethargy, poor perfusion, and acidosis. She
was then transferred to the ICU at our tertiary care facility where hemodynamic support was provided and a
chest tube was placed. Blood cultures drawn from the
community hospital grew S. pyogenes and penicillin
(300,000 units/kg/day) and clindamycin were started.
Repeat blood cultures at our institution were also positive for S. pyogenes. Due to hemodynamic instability, a
transthoracic echocardiogram was performed to assess
cardiac function. The study was limited by clinical instability but did not show evidence of endocarditis.
In addition to hypotension, she developed multi-organ
dysfunction including acute renal failure, elevated liver
Page 2 of 6
Casea
# [ref]
Year Age,
Sex
Pre-existing cardiac
abnormalities
Preceding
infection
Valve(s)
affected
Complications
Emboli
1 [12]
1942 2y, M
None
None
Mitral
Splenomegaly
Brain, Peripheral, No
Renal, Spleen
Death
None
No
Not reported
No
Death
Bronchopneumonia
Surgery Outcome
1975 6 m, M None
Meningitis
Aortic
Microscopic hematuria
LVHb
Aortic insufficiency and CHFc
Left sinus of Valsalva aneurysum
3 [13]
1977 14y, M
Aortic
Myocardial abscesses
Rupture of sinus of Valsalva
into left ventricle
4 [4]
1980 16y, M
None
5 [2]
1984 2y, M
Pulmonic stenosis
None
Peripheral, Renal No
Recovered
Brain, Spleen
No
Death
None
No
Death
None
Yes
Brain, Peripheral
No
Table 1 Cases of S. pyogenes endocarditis from 1940 to present for which clinical features are available
Aortic insufficiency
Proliferative glomerulonephritis
6 [6]
1988 4 m, F
None
Varicella
Aortic
Para-aortic abscess
CHF and pulmonary edema
c
7 [14]
1988 4y, F
None
None
Aortic
Polyarthritis
Aortic regurgitation
Sinus of Valsalva aneurysm
8 [7]
1992 3y, F
None
None
Mitral
Left-sided hemiparesis
Microscopic hematuria
Mitral regurgitation
Pericardial effusion
Required vasopressors
and intubation
1999 5 m, M None
None
Mitral
Brain
No
Recovered with
left-sided weakness
Varicella
Mitral
Seizure
Peripheral
Yes
Recovered
Respiratory failure
Hypotension
Page 3 of 6
10 [5]
None
2000 4y, M
None
None
Mitral
Mitral regurgitation
Left foot
Yes
Recovered
Brain, Peripheral
Yes
Recovered with
left hemiplegia
Peripheral
Yes
Recovered
Necrosis of 2 toes
requiring amputation
12 [16]
2000 2y, M
None
Varicella
Aortic
13 [8]
2000 3y, M
None
Varicella
Aortic
Joint pain
Bilateral pulmonary infiltrates
Elevated LFTse
Table 1 Cases of S. pyogenes endocarditis from 1940 to present for which clinical features are available (Continued)
Aortic insufficiency
Left ventricular dilatation leading to CHFc
a
Includes all cases from which clinical features, demographics, and outcome can be extracted. There exists an additional group of cases of possible S. pyogenes endocarditis in children for which sufficient clinical data
is not available [1,17-21]. As well, a few cases were excluded due to ambiguity [21,22].
b
LVH = left ventricular hypertrophy.
c
CHF = congestive heart failure.
d
VSD = ventricular septal defect.
e
LFTs = liver function tests.
Page 4 of 6
Page 5 of 6
Competing interests
The authors declare that they have no competing interests.
Conclusions
In summary, we present a rare combination of endocarditis caused by S. pyogenes in two children with previously normal hearts admitted to the same hospital in a
Consent
Written informed consent was obtained from the patients parents for publication of these case reports.
Consent was documented in the patients charts according to The Hospital for Sick Childrens Consent for Publication/Presentation of Case Reports Policy. Copies are
available for review upon request.
Abbreviations
ASD: Atrial septal defect; AV: Atrioventricular; CT: Computed tomography;
ECG: Electrocardiogram; Echo: Echocardiogram; ED: Emergency department;
ICU: Intensive care unit; IE: Infective endocarditis; PFO: Patent foramen ovale.
Authors contributions
DW, HA, and SM participated in the direct care of the patients. DW
conducted the literature review and prepared the first draft of the
manuscript. HA assisted with manuscript drafting. SM designed the project,
edited the manuscript, and provided overall supervision for the project.
All authors read and approved the final manuscript.
Acknowledgements
We thank the Toronto Invasive Bacterial Diseases Network and Canadas
National Microbiology Laboratory for emm typing.
Author details
1
Department of Pediatrics, The Hospital for Sick Children, 555 University
Avenue, M5G 1X8 Toronto, Ontario, Canada. 2Division of Infectious Diseases,
The Hospital for Sick Children, Toronto, Canada. 3University of Toronto,
Toronto, Canada. 4Peter Gilligan Research Institute, Toronto, Canada.
Received: 19 March 2014 Accepted: 26 August 2014
Published: 10 September 2014
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doi:10.1186/1471-2431-14-227
Cite this article as: Weidman et al.: Two cases and a review of
Streptococcus pyogenes endocarditis in children. BMC Pediatrics 2014 14:227.