Lactational amenorrhea as a risk factor for group a streptococcal vaginitis

Group A Streptococcal Toxic Shock Syndrome after a Routine Gynecological Procedure

Streptococcal toxic shock syndrome (STSS) is a life-threatening illness mainly caused by invasive group A Streptococcus (GAS) infection. Herein, we report a case of a postmenopausal woman who developed STSS from an ascending vaginal GAS infection after cytocervical sampling. The patient complained of vaginal discharge, for which she underwent gynecological examination with vaginal sampling. The following day, there was onset of diarrhea and vomiting. After 7 days, she was admitted to our hospital with septic shock. Necrotizing enterocolitis was suspected and surgical intervention was performed; however, the patient was diagnosed with primary peritonitis and antibiotics were initiated. On day 2, GAS was suspected by blood cultures, and antibiotics were changed in consideration of STSS. On day 4, GAS was confirmed in blood, ascitic fluid, and vaginal swab specimens, and STSS caused by an ascending vaginal GAS infection was diagnosed. This case report indicates that STSS could occur following cytocervical sampling for vaginal discharge. If a woman has unexplained septic shock, especially with gastroenteritis symptoms, STSS should be considered as a differential diagnosis.

Streptococcal toxic shock syndrome following group A streptococcal vulvovaginitis in a breastfeeding woman

Streptococcal toxic shock syndrome (STSS) is a systemic, life-threatening illness usually caused by invasive respiratory tract or skin and soft tissue infections of Streptococcus pyogenes (group A streptococcus, GAS). We report the case of an adult woman with lactational amenorrhea and GAS vulvovaginitis progressing to STSS. She was admitted to our hospital because of fever, lethargy, and a 2-week history of vaginal discharge; she also had hypotension and multiple organ failure. Blood and urine cultures yielded gram-positive cocci and GAS. After 14 days of antimicrobial therapy, she fully recovered without any complications. The vulvovaginitis was most likely the portal of entry for GAS, which is rarely recognized as a causative pathogen of vulvovaginitis. Lactational amenorrhea is thought to be a risk factor for GAS vulvovaginitis. It is important for clinicians to recognize the possibility of GAS vulvovaginitis in breastfeeding women with vaginal symptoms and consider the necessity of prompt antibiotic treatment.

Streptococcal toxic shock syndrome secondary to group A Streptococcus vaginitis

Streptococcal toxic shock syndrome (TSS) is a systemic illness usually caused in the setting of infection by group A Streptococcus (GAS). The primary infections are often invasive infections of the respiratory tract or necrotizing infections of the skin and soft tissue, but some infections occur without relevant focus. GAS vaginitis is a rare condition among adult women and is accordingly thought to be uncommon as a cause of streptococcal TSS. Here we report the cases of two postmenopausal women with streptococcal TSS secondary to GAS vaginitis, one aged 55 and one aged 60. Both came to our emergency department with complaints or symptoms of abdominal pain, fever, hypotension, and multi-organ failure. In both cases, the relevant factor associated with streptococcal infection was a recent episode of GAS vaginitis. Both underwent fluid management and 14 days of antibiotic treatment and fully recovered without complications. Vaginitis was likely to be the primary infectious trigger of TSS in these two cases. Intrauterine device insertion, endometrial biopsy, and post-partum state have all been previously reported in TSS patients, and the female genital tract has been described as a portal of entry. GAS vaginitis warrants appropriate treatment as it may progress to severe systemic infection as described.

Observational study of Streptococcus pyogenes isolated from vaginal swabs of adult women in a hospital and community laboratory

AIMS

Streptococcus pyogenes or group A streptococcus (GAS) is a common cause of vulvo-vaginitis in pre-pubertal females but is uncommonly isolated from the vaginal swabs of adult females. We aimed to describe the clinical and laboratory findings of adult females with GAS isolated from vaginal swabs in a community and hospital laboratory.

METHODS

Over a 19 week period the two laboratories identified females ≥ 15 years of age with GAS isolated from vaginal swabs. At least 2 weeks after reporting, the referring doctor or midwife was telephoned by the authors for clinical information or the clinical notes were reviewed. Laboratory data were also collected.

RESULTS

One hundred adult females with GAS isolated from vaginal swabs were identified from approximately 4500-5000 community laboratory, and 20 from approximately 2000 hospital laboratory swabs. Community patients were more likely to have presented with vaginal symptoms such as discharge, while hospital patients were more likely to have ascending infection related to pregnancy/recent delivery. Of the community patients, 15% were asymptomatic compared with 5% of the hospital patients. Review of Gram stain and culture quantification was not found to be particularly useful for discriminating between clinical infection and asymptomatic colonisation.

CONCLUSIONS

Isolation of GAS from the vaginal swabs of adult females is uncommon. In the community setting it may represent infection with vulvo-vaginitis or asymptomatic colonisation. In the hospital setting, its isolation is frequently associated with pregnancy-related infectious complications.

Murine vaginal colonization model for investigating asymptomatic mucosal carriage of Streptococcus pyogenes

While many virulence factors promoting Streptococcus pyogenes invasive disease have been described, specific streptococcal factors and host properties influencing asymptomatic mucosal carriage remain uncertain. To address the need for a refined model of prolonged S. pyogenes asymptomatic mucosal colonization, we have adapted a preestrogenized murine vaginal colonization model for S. pyogenes. In this model, derivatives of strains HSC5, SF370, JRS4, NZ131, and MEW123 established a reproducible, asymptomatic colonization of the vaginal mucosa over a period of typically 3 to 4 weeks' duration at a relatively high colonization efficiency. Prior treatment with estradiol prolonged streptococcal colonization and was associated with reduced inflammation in the colonized vaginal epithelium as well as a decreased leukocyte presence in vaginal fluid compared to the levels of inflammation and leukocyte presence in non-estradiol-treated control mice. The utility of our model for investigating S. pyogenes factors contributing to mucosal carriage was verified, as a mutant with a mutation in the transcriptional regulator catabolite control protein A (CcpA) demonstrated significant impairment in vaginal colonization. An assessment of in vivo transcriptional activity in the CcpA(-) strain for several known CcpA-regulated genes identified significantly elevated transcription of lactate oxidase (lctO) correlating with excessive generation of hydrogen peroxide to self-lethal levels. Deletion of lctO did not impair colonization, but deletion of lctO in a CcpA(-) strain prolonged carriage, exceeding even that of the wild-type strain. Thus, while LctO is not essential for vaginal colonization, its dysregulation is deleterious, highlighting the critical role of CcpA in promoting mucosal colonization. The vaginal colonization model should prove effective for future analyses of S. pyogenes mucosal colonization.

Gram-positive bacterial superantigen outside-in signaling causes toxic shock syndrome

Staphylococcus aureus and Streptococcus pyogenes (group A streptococci) are Gram-positive pathogens capable of producing a variety of bacterial exotoxins known as superantigens. Superantigens interact with antigen-presenting cells (APCs) and T cells to induce T cell proliferation and massive cytokine production, which leads to fever, rash, capillary leak and subsequent hypotension, the major symptoms of toxic shock syndrome. Both S. aureus and group A streptococci colonize mucosal surfaces, including the anterior nares and vagina for S. aureus, and the oropharynx and less commonly the vagina for group A streptococci. However, due to their abilities to secrete a variety of virulence factors, the organisms can also cause illnesses from the mucosa. This review provides an updated discussion of the biochemical and structural features of one group of secreted virulence factors, the staphylococcal and group A streptococcal superantigens, and their abilities to cause toxic shock syndrome from a mucosal surface. The main focus of this review, however, is the abilities of superantigens to induce cytokines and chemokines from epithelial cells, which has been linked to a dodecapeptide region that is relatively conserved among all superantigens and is distinct from the binding sites required for interactions with APCs and T cells. This phenomenon, termed outside-in signaling, acts to recruit adaptive immune cells to the submucosa, where the superantigens can then interact with those cells to initiate the final cytokine cascades that lead to toxic shock syndrome.

Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women

PURPOSE

Vaginal infection with group A streptococci (GAS) is an established cause of vaginitis amongst prepubescent girls, but largely unrecognized in adult women and therefore often misdiagnosed as vulvovaginal candidosis. We sought to give an overview of the epidemiology, risk factors, symptoms, signs, and treatment of GAS vaginitis in adult women.

METHODS

Systematic literature search.

RESULTS

We identified nine case reports covering 12 patients with documented GAS vulvovaginitis. GAS vulvovaginitis in adult women is often associated with a predisposing factor: (1) household or personal history of dermal or respiratory infection due to GAS, (2) sexual contact, and (3) lactational or menopausal vaginal atrophy. Symptoms of GAS vulvovaginitis in adult women may include vaginal and/or vulvar pain, dyspareunia, burning sensation or irritation, and pruritus. In most cases, there is also profuse or copious vaginal discharge which may be watery, yellow, or even purulent. Whilst there are neither clinical trials nor treatment guidelines, treatment with oral penicillin or with vaginal clindamycin cream has been reported to result in rapid cure. In breast-feeding and postmenopausal women with vaginal atrophy, additional treatment with local estriol may be necessary to prevent recurrence. Finally, in case of recurrent GAS vulvovaginitis it will be necessary to assess the patients' asymptomatic household members for pharyngeal and anal carriage and to treat them accordingly.

CONCLUSION

Vaginal infection with GAS in adult women is a clearly defined entity and should be considered a diagnosis when more common causes of vaginitis have been ruled out.

Interactions of Lactobacilli with pathogenic Streptococcus pyogenes

Objective. To determine whether (1) a decreased concentration of Lactobacilli allows S. pyogenes to grow; (2) S. pyogenes is able to grow in the presence of healthy Lactobacillus concentrations; (3) S. pyogenes is capable of inhibiting Lactobacilli. Methods. One hundred fifty patient samples of S. pyogenes were mixed with four different concentrations of L. crispatus and L. jensenii. Colony counts and pH measurements were taken from these concentrations and compared using t-tests and ANOVA statistical analyses. Results. Statistical tests showed no significant difference between the colony counts of S. pyogenes by itself and growth when mixed with Lactobacilli, and no significant difference between the colony counts of S. pyogenes in the four different concentrations of Lactobacilli. Conclusion. The statistical data representing the growth of these two organisms suggests that Lactobacilli did not inhibit the growth of S. pyogenes. Also, S. pyogenes did not inhibit the growth of Lactobacilli.