Balanitis caused by group A beta-hemolytic streptococci

Streptococcus pyogenes balanoposthitis

The main causative organism of balanoposthitis in sexually active adolescents is reportedly the group B hemolytic streptococcus. While cases of balanoposthitis caused by group A streptococcal infection in children have been reported, their occurrence in the adolescent age group is relatively rare.

We describe a case of balanoposthitis caused by Streptococcus pyogenes (group A streptococcus) in a 31-year-old man who presented to the hospital with complaints of pain and swelling in his penile foreskin for the past 6 days. The patient was treated successfully by performing a ventral incision on the foreskin and administering effective antimicrobial therapy involving amoxicillin 750 mg/day. Group A beta-hemolytic Streptococcus pyogenes should also be considered a causative organism in the differential diagnosis, while managing a patient with balanoposthitis.

Penile Inflammatory Skin Disorders and the Preventive Role of Circumcision

Penile inflammatory skin conditions such as balanitis and posthitis are common, especially in uncircumcised males, and feature prominently in medical consultations. We conducted a systematic review of the medical literature on PubMed, EMBASE, and Cohrane databases using keywords "balanitis," "posthitis," "balanoposthitis," "lichen sclerosus," "penile inflammation," and "inflammation penis," along with "circumcision," "circumcised," and "uncircumcised." Balanitis is the most common inflammatory disease of the penis. The accumulation of yeasts and other microorganisms under the foreskin contributes to inflammation of the surrounding penile tissue. The clinical presentation of inflammatory penile conditions includes itching, tenderness, and pain. Penile inflammation is responsible for significant morbidity, including acquired phimosis, balanoposthitis, and lichen sclerosus. Medical treatment can be challenging and a cost burden to the health system. Reducing prevalence is therefore important. While topical antifungal creams can be used, usually accompanied by advice on hygiene, the definitive treatment is circumcision. Data from meta-analyses showed that circumcised males have a 68% lower prevalence of balanitis than uncircumcised males and that balanitis is accompanied by a 3.8-fold increase in risk of penile cancer. Because of the high prevalence and morbidity of penile inflammation, especially in immunocompromised and diabetic patients, circumcision should be more widely adopted globally and is best performed early in infancy.

Antibiotic Resistance of Non-pneumococcal Streptococci and Its Clinical Impact

The taxonomy of streptococci has undergone major changes during the last two decades. The present classification is based on both phenotypic and genotypic data. Phylogenetic classification of streptococci is based on 16S rRNA sequences [1], and it forms the backbone of the overall classification system of streptococci. Phenotypic properties are also important, especially for clinical microbiologists. The type of hemolysis on blood agar, reaction with Lancefield grouping antisera, resistance to optochin, and bile solubility remain important for grouping of clinical Streptococcus isolates and therefore treatment options [2]. In the following chapter, two phenotypic classification groups, viridans group streptococci (VGS) and beta-hemolytic streptococci, will be discussed.

Antibiotic Resistance of Non-Pneumococcal Streptococci and Its Clinical Impact

Viridans streptococci (VGS) form a phylogenetically heterogeneous group of species belonging to the genus Streptococcus (1). However, they have some common phenotypic properties. They are alfa- or non-haemolytic. They can be differentiated from S. pneumoniae by resistance to optochin and the lack of bile solubility (2). They can be differentiated from the Enterococcus species by their inability to grow in a medium containing 6.5% sodium chloride (2). Earlier, so-called nutritionally variant streptococci were included in the VGS but based on the molecular data they have now been removed to a new genus Abiotrophia (3) and are not included in the discussion below. VGS belong to the normal microbiota of the oral cavities and upper respiratory tracts of humans and animals. They can also be isolated from the female genital tract and all regions of the gastrointestinal tract (2, 3). Several species are included in VGS and are listed elsewhere (2, 3). Clinically the most important species belonging to the VGS are S. mitis, S. sanguis and S. oralis.

Why circumcision is a biomedical imperative for the 21(st) century

Circumcision of males represents a surgical "vaccine" against a wide variety of infections, adverse medical conditions and potentially fatal diseases over their lifetime, and also protects their sexual partners. In experienced hands, this common, inexpensive procedure is very safe, can be pain-free and can be performed at any age. The benefits vastly outweigh risks. The enormous public health benefits include protection from urinary tract infections, sexually transmitted HIV, HPV, syphilis and chancroid, penile and prostate cancer, phimosis, thrush, and inflammatory dermatoses. In women circumcision of the male partner provides substantial protection from cervical cancer and chlamydia. Circumcision has socio-sexual benefits and reduces sexual problems with age. It has no adverse effect on penile sensitivity, function, or sensation during sexual arousal. Most women prefer the circumcised penis for appearance, hygiene and sex. Given the convincing epidemiological evidence and biological support, routine circumcision should be highly recommended by all health professionals.

RACP's policy statement on infant male circumcision is ill-conceived

OBJECTIVE

To conduct a critical peer-review of the 2004 Policy Statement on routine male circumcision produced by the Royal Australasian College of Physicians (RACP).

METHOD

Comprehensive evaluation in the context of the research field.

RESULTS

We find that the current Statement downplays the wide-ranging life-long benefits of circumcision in prevention of urinary tract infections (UTIs), penile and cervical cancer, genital herpes and chlamydia in women, HIV infection, phimosis, and various penile dermatoses, and at the same time overstates the complication rate. We highlight the many errors in the RACP Statement and note that it sidesteps making a conclusion based on circumcision's well-documented prophylactic health benefits by instead referring to the status of the foreskin at birth. In the era of preventative medicine we view this as irresponsible.

CONCLUSION

The RACP's Statement on routine male circumcision is not evidence-based and should be retracted.

IMPLICATIONS

In the interests of public health and individual well-being an extensive, comprehensive, evidence-based revision should be conducted so as to provide scientifically accurate, balanced information on the advantages, and also the low rate of mostly minor complications, associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period.

Streptococcus pyogenes : une cause exceptionnelle d'urétrite et de balanite non gonococcique de l'adulte

Urethritis and balanitis due to S. pyogenes are very uncommon. The authors report the case of a 22 year-old male patient, presenting with this association, the first case reported in France. There was no associated STD.

Extrapharyngeal group A Streptococcus infection: diagnostic accuracy and utility of rapid antigen testing

BACKGROUND

Antigen tests have been well-studied and are widely used in pediatric practice for rapid detection of group A Streptococcus (GAS) infections in the throat, but they have not been examined sufficiently for the detection of infection of skin sites, such as the perineal region or impetiginous lesions.

METHODS

During the 3-year period 1999 to 2002, we evaluated 239 patients with suspected GAS skin infection, in 5 pediatric practices, using 3 Dacron swabs for each site. The first swab was tested in the pediatric office laboratory with an antigen detection kit. For the first 91 patients, the Abbott Test Pack Plus antigen detection test (ADT) was used. The Abbott Signify Strep A ADT was used to test subsequent patients. The second swab was tested with BD Directigen 1-2-3 ADT in the hospital laboratory. The third swab was placed in modified Stuart's transport medium for comparison of recovery of GAS from culture in broth or on agar. A positive culture served as the reference standard. Test performance and test accuracy were determined for each ADT.

RESULTS

Of the 247 ADTs and cultures performed on 239 patients, 91 with suspected skin infection were tested with the Test Pack Plus test, 149 with the Signify Strep A test and 247 with the Directigen test. Eighty-six (35%) cultures were positive, 73 from perineal sites (54 rectal, 13 vaginal, 6 penile) and 13 from impetiginous lesions. There was 100% concordance for the 86 cultures positive for GAS in a comparison between dry Dacron swabs and swabs that had been placed in modified Stuart's transport medium. Test Pack Plus and Signify Strep A ADTs had similar performance characteristics for skin infections: sensitivity, 92 and 88%; specificity, 99 and 97%; positive predictive value, 96 and 94%; and negative predictive value, 97 and 93%. Directigen ADT had sensitivity 78%, specificity 100%, positive predictive value 100% and negative predictive value 89%. Accuracy for the tests varied from 92 to 97%.

CONCLUSION

Tests designed to detect GAS carbohydrate antigen in patients with pharyngitis can be used rapidly and accurately to detect GAS antigen in patients with cutaneous lesions suspected of GAS infection.

Perineal group A streptococcal disease in a pediatric practice

OBJECTIVE

This study was designed to document the frequency and define the clinical, epidemiologic, and microbiologic characteristics of perineal disease caused by group A beta-hemolytic streptococci (GAS) in a pediatric practice in which increased numbers of cases had been observed.

METHODS

Clinical, epidemiologic, and microbiologic data were collected on all culture-confirmed cases of perineal GAS disease during the calendar year 1997. GAS isolates from clinical cases and a comparison group of children with GAS pharyngitis were analyzed by T typing, emm gene analysis, and pulsed-field gel electrophoresis (PFGE).

RESULTS

Twenty-three cases of GAS perineal disease were diagnosed during 4530 office visits in 1997. Thirteen cases had perianal disease, 8 had vulvovaginal infection, and 2 were infected at both sites. No cases of penile disease were identified. Infections peaked in late winter and early spring and affected children with an average age of 5 years with a range of perineal, gastrointestinal, and genitourinary symptoms. Analysis of T and emm types showed the majority (82%) of perineal isolates to be T 28 emm 28, showing 2 closely related PFGE patterns. In contrast, the pharyngeal isolates were distributed among 6 different T and emm types.

CONCLUSION

Perineal infection caused by GAS may be a relatively common diagnosis in a pediatric or family practice setting. There may be specific GAS types that have a tropism for perineal tissues but the mechanism of infection is yet to be established.

Penile cellulitis

A37-year-old married man presented to his GP with a 4-day history of itching and painless swelling of his penis. He was treated with a compound antifungal, anti-inflammatory disinfectant cream (Timodine cream, Reckitt & Colman, Hull) without response. Three days later, the patient attended the accident and emergency department at his local hospital with the same complaint. He was diagnosed as having an ‘infected penis’, and was advised instead to attend the genitourinary medicine (GUM) clinic.

At the GUM clinic, the patient denied any history of allergy or genital trauma before his complaint. He was in a monogamous sexual relationship with his wife, and only practised peno-insertive vaginal intercourse. He had sexual intercourse 2 weeks previously. There was no significant past medical history.

On examination, he was overweight and apyrexial. There was a painless diffusely swollen penis with a ring of crusts at the tip of the foreskin and purulent discharge around the glans penis. There was no urethral discharge and no inguinal lymphadenopathy (Figure 1). There was tenderness on attempting to retract the foreskin. Routine urinalysis for pyuria and proteinuria were negative. Screening for urethral gonococcal and chlamydial infections were negative. However, culture of the purulent discharge taken from the subpreputial sac grew beta-haemolytic group A Streptococcus pyogenes. The patient was initially treated with a 2-week course of amoxycillin and flucloxacillin, and his condition improved dramatically after 4 days.

Circumcision and pediatric disorders of the penis

Circumcision is a commonly performed procedure, but medical indications remain controversial. Most disorders of the penis in childhood can be diagnosed and managed by the primary care pediatrician. However, some require early recognition and surgical intervention, and prompt referral to a pediatric surgeon or urologist will optimize outcome. This article discusses the recognition and initial management of these problems, particularly those most commonly seen or followed in the outpatient setting. In addition, the authors review the issues of circumcision.