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LETTER TO EDITOR Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 132-133
Group A Streptococcus meningitis: Microbiological evidence clinches the issue


1 Department of Microbiology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi - 110 095, India
2 Department of Neurology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi - 110 095, India

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How to cite this article:
Thakur R, Sarma S, Bala K. Group A Streptococcus meningitis: Microbiological evidence clinches the issue. Indian J Pathol Microbiol 2009;52:132-3

How to cite this URL:
Thakur R, Sarma S, Bala K. Group A Streptococcus meningitis: Microbiological evidence clinches the issue. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Dec 14];52:132-3. Available from: http://www.ijpmonline.org/text.asp?2009/52/1/132/44984


Sir

Group A beta hemolytic Streptococcus (GAS) invasive disease has become increasingly common in recent years. Although GAS is a frequent colonizer of the oropharynx, meningitis due to GAS has been reported in association with upper respiratory tract infections, otitis media, sinusitis, head injuries and cranial surgeries following cochlear implantation and iatrogenic procedures like lumbar punctures. [1],[2],[3] GAS bacterial meningitis, though on the rise, accounts for 0.2-1% of all bacterial meningitis and is still an uncommon pathogen of adult pyogenic meningitis. [4],[5] Here, we report a case of GAS meningitis in a previously healthy adult male who responded very well to antimicrobial therapy.

A 35-year-old male presented with altered sensorium and severe ataxia of 3 days duration. There was a history of high-grade fever with associated upper respiratory tract infection (URTI) and headache about 8 days earlier following that the patient complained of bilateral partial hearing loss. There was no history of trauma, seizures, focal neurological deficit, ear discharge, or cyanosis. The patient had been a known alcoholic for the past 15 years.

On examination the patient was drowsy, afebrile with a normal pulse rate, respiratory rate and blood pressure. His pupils were equal and reacting to light, a fundus examination was normal and there was bilateral conjunctival congestion. There was no cranial nerve involvement or focal deficit but the plantar response was extensor bilaterally and all the signs of meningial irritation were present. The respiratory, cardiovascular and abdominal examinations were essentially normal.

Laboratory investigations showed hemoglobin levels of 13 gm/dl and a leukocyte count of 5730/cu mm (neutrophils 89%, lymphocytes 9% and monocytes 2%). Random blood sugar was 143 mg/dl and liver function tests were abnormal (SGOT 48 IU/L, SGPT 68 IU/L, ALP 50 IU/L, total protein 5.5 gm/dl with a normal albumin globulin ratio). Serum electrolytes, renal function tests, arterial blood gas analysis and urine analysis were within normal limits. A peripheral blood smear examination did not reveal any malarial parasites. Magnetic resonance imaging (MRI) of the brain was inconclusive.

Cerbrospinal fluid (CSF) was pale yellow in color and contained 9 leucocytes/cu mm (5 neutrophils). CSF protein was 120 mg/dl and glucose was below the detection level. A microbiological evaluation of the CSF showed gram positive cocci in pairs and short chains and its culture yielded GAS after 24 hrs of incubation. The isolate was identified by colony morphology, staining characteristics, sensitivity to Bacitracin and was confirmed by a latex agglutination test (Streptex; remel). An antibiogram revealed the isolate to be sensitive to penicillin, erythromycin, ciprofloxacin, chloramphenicol, ceftriaxone and clindamycin.

A blood culture also yielded growth of GAS after 24 hrs of aerobic incubation. Antibiotic susceptibility was also similar to the CSF isolate. The patient was given ceftriaxone (2 gm 12 hourly, intravenously) and vancomycin (1 gm 12 hourly, intravenously) for 10 days and his condition started improving within 3 days of the beginning of treatment. The patient was discharged after 2 weeks of admission with no significant residual neurological deficit except persistent hearing loss for which he was referred for an ENT consultation.

Meningitis due to GAS in adults is relatively uncommon. In a MEDLINE search of world literature, 55 cases of GAS meningitis have been reported. In older children and adults, contiguous infective foci like acute otitis media are most frequently associated with the disease but in many cases a primary focus is not identified. There are only four reported cases of GAS meningitis from India out of which only one of the patients was an adult who did not recover in spite of aggressive therapy. GAS meningitis usually has a more favorable outcome in adults compared with children but there are recent reports of adult GAS meningitis with fulminant outcomes. [6]

The patient in our setting was initially diagnosed as a case of meningoencephalitis with alcohol withdrawal syndrome. A definitive etiological diagnosis of pyogenic meningitis was made only after isolation of GAS from CSF and blood supported by a neutrophilic leucocytosis. Excellent clinical response to antibiotic therapy with ceftriaxone and vancomycin further proved the point. The source of infection in this case could have been upper respiratory tract or middle ear infection, which could also explain his hearing loss.

This case underscores the fact that GAS must be considered in the differential diagnosis of acute pyogenic meningitis beyond the neonatal period. Clinicians need to be aware of the fact that GAS can be a causative agent of meningitis and can have a fulminant course necessitating prompt diagnosis and aggressive therapy. The disease burden can only be assessed by rapid microbiological diagnosis and documentation of GAS meningitis in different settings. Further, recommendations need to be formulated for post exposure antibiotic prophylaxis in close contacts of such cases.

 
   References Top

1.Asnis DS, Knez T. Group A Streptococcal meningitis. Arch Intern Med 1998;58:810-4.  Back to cited text no. 1    
2.Hsu J, Jensen B, Arduino M, Bergeron T, Fox T, Gum G, et al . Streptococcal meningitis following myelogram procedures. Infect Control Hosp Epidemiol 2007;28:614-7.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Pettersen G, Ovetchkine P, Tapiero B. Group A streptococcal meningitis in a pediatric patient following cochlear implantation: Report of the first case and review of the literature. J Clin Microbiol 2005;43:5816-8.   Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Steppberger K, Adams I, Deutscher J, Müller H, Kiess W. Meningitis in a girl with recurrent otitis media caused by Streptococcus pyogenes-otitis media has to be treated appropriately. Infection 2001;29:286-8.   Back to cited text no. 4    
5.Van de Beek D, de Gans J, Spanjaard L, Sela S, Vermeulen M, Dankert J. Group A Streptococcal meningitis in adults: Report of 41 cases and a review of the literature. Clin Infect Dis 2002;34:e32-6.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Mani R, Mahadevan A, Pradhan S, Nagarathna S, Srikanth NS, Dias M, et al . Fatal Group A Streptococcal meningitis in an adult. Indian J Med Microbiol 2007;25:169-70.   Back to cited text no. 6  [PUBMED]  Medknow Journal

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Correspondence Address:
Rajeev Thakur
Department of Microbiology, Institute of Human Behaviour and Allied Sciences (IHBAS), Dilshad Garden, Delhi - 110 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.44984

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