Streptococci and the genital tract

Haemophilus parainfluenzae-related cellulitis of the penis following tearing of a short frenulum

INTRODUCTION

Infectious cellulitis is a common disease, mostly affecting the lower extremities and the face but only rarely the genitalia.

OBSERVATION

A 24-year-old male patient presented with acute erythematous edema of the penile shaft and foreskin present for 48hours. Gentle retraction of the foreskin revealed a short frenulum with a small area (2-3mm) of erosion. He had had unprotected genital and orogenital sex three days before with his usual female partner and reported tearing of the frenulum during intercourse. Ampicillin-sensitive Haemophilus parainfluenzae was isolated from the swab taken from the erosion of the frenulum. Clinical remission was obtained following oral administration of amoxicillin and clavulanic acid.

DISCUSSION

We describe not only the first case of Haemophilus parainfluenzae-associated cellulitis of the penis but also the first report of penile cellulitis following erosion of a short frenulum during sexual intercourse.

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.

Recurrent group A streptococcal vulvovaginitis in adult women: family epidemiology

Group A beta-hemolytic streptococcal (GAS) vulvovaginitis has been reported in prepubertal girls. In adult women, a vaginal carrier state has been described, but vulvovaginitis is rarely reported. We describe 2 cases of recurrent GAS vulvovaginitis in women whose husbands were gastrointestinal carriers of GAS. Characterization of the isolated strains demonstrated that identical emm types of GAS were shared by partners. Treatment of both partners resulted in resolution of vaginitis. On the basis of negative vaginal culture results obtained after treatment of each individual episode of vaginitis, we believe that the female patients were reinfected as a result of exposure to their husbands, with shedding likely to have occurred in bed. These cases reiterate the necessity for adequate screening of the patient's family and contacts in cases of recurrent GAS infection by culturing all potential areas of GAS carriage.

Two cases of group A streptococcal vulvovaginitis in premenopausal adults in a sexual health setting

Two cases of group A streptococcus (GAS) causing vulvovaginitis in premenopausal adults are described. A review of the literature of genital GAS is made, as this is an uncommon cause of vulvovaginitis in premenopausal adults. Contrasts are made between anogenital carriage of GAS and group B streptococcus (GBS) to highlight the differences in anogenital carriage between these two organisms.

A comparative study of clinical management strategies for vaginal discharge in family planning and genitourinary medicine settings

OBJECTIVE

To compare strategies for management of women with vaginal discharge in genitourinary medicine (GUM) and family planning (FP) settings.

METHODS

The setting was a centre housing both FP and GUM departments within a primary care trust in Scotland. The study participants were 200 women presenting with vaginal discharge. A randomised, controlled, crossover design was employed. Strategies typical of FP and GUM were performed on every participant in a randomised sequence. Day 1 diagnoses were made by the FP strategy (history and examination) and the GUM strategy (nearpatient microscopy added). Day 7 results were obtained from final analysis of all specimens. Days 1 and 7 results were compared with the reference standard provided by all the test results. The main outcome measures were incorrect diagnoses on Days 1 and 7.

RESULTS

On Day 1 the FP strategy resulted in significantly more incorrect diagnoses than the GUM strategy when compared with the reference standard (73 vs 32; p <0.001). On Day 7 the GUM strategy resulted in significantly more incorrect diagnoses than the FP strategy when compared with the reference standard (32 vs 17; p = 0.019).

CONCLUSIONS

Vaginal discharge can be managed effectively in community settings such as FP and primary care. The addition of near-patient microscopy produces a more accurate immediate diagnosis. The addition of a high vaginal swab for culture produces a more accurate final diagnosis. The costs of on-site microscopy must be considered.

Recurrent group A Streptococcal genital infection after Puerperal sepsis

Recurrent group A streptococcal infection is a well-known phenomenon. It is well documented as a problem in pharyngotonsillitis and skin infections. This report describes a case of recurrent genital infection after puerperal sepsis caused by group A streptococci.

Group B streptococcus carriage and vulvovaginal symptoms: causal or casual? A case-control study in a GUM clinic population

OBJECTIVES

The isolation of group B streptococcus (GBS) on routine swabs taken from genitourinary medicine (GUM) clinic attendees is a common finding. The relation of GBS to vulvovaginal symptoms is unclear, creating confusion about management. This case-control study tested the hypothesis that detection of GBS on routine clinical specimens is not causally related to vulvovaginal symptoms in female GUM clinic attendees.

METHODS

Data were collected on all female GUM clinic attendees who had GBS isolated from anogenital swabs between July 1999 and July 2001. Controls were randomly selected from all new and rebooking female GUM clinic attendees. Controls were group matched for age with cases and were included only if a sexual health screen was performed and the results of this were available.

RESULTS

118 cases and 308 controls were identified during the study period. There was no significant difference between cases and controls in patient demographic or behavioural characteristics, the presence of genital co-infection, or vulvovaginal symptoms. There was no relation between symptoms and quantitative growth of GBS reported by the laboratory in either cervical or urethral swabs. Only nine cases had high vaginal swabs taken, in whom there was a significant association between a heavy growth of GBS and vulvovaginal symptoms (p=0.008).

CONCLUSION

The isolation of GBS from routinely collected genital swabs in female attendees of a GUM clinic is not causally related to vulvovaginal symptoms. We recommend that patients should receive this advice and should not be treated with antibiotic therapy for this indication.

Vaginal bacterial flora of pregnant women colonized with group B streptococcus

To elucidate the characteristics of group B streptococcus (GBS)-positive vaginal flora in pregnant women, vaginal cultures were conducted in 4025 women at 22 to 36 weeks of gestation. The results were analyzed by Fisher's exact test. Among 4025 women, 408 were found to be GBS positive and 3617 were GBS negative (GBS-negative group). A total of 1151 bacterial strains were recovered in the GBS-positive group and 6746 strains in the GBS-negative group. The percentages of Gram-positive cocci other than GBS, anaerobes, fungi, and Lactobacillus were 18.8%, 1.4%, 6.0%, and 34.4%, respectively, in the GBS-positive group, and 30.4%, 4.1%, 8.8%, and 53.5% in the GBS-negative group. The percentages were significantly lower in the GBS-positive group ( P < 0.0001, P < 0.0001, P= 0.0012, P < 0.0001, respectively). Judging from the reduction in Lactobacillus, the GBS-positive vaginal flora is not considered a normal flora. However, it is not regarded as a pathogenic flora either, because the isolation rates of anaerobes (strongly associated with bacterial vaginosis) and fungi (occasionally causing vulvovaginal candidiasis) were lower than in the GBS-negative flora. These results suggest that the GBS-positive flora is associated with a lower risk of abnormality during pregnancy and abnormal pregnancy outcome compared with the GBS-negative flora, although this group is one of the most important pathogens in neonatal infections.

Increased maternal mortality in The Netherlands from group A streptococcal infections

OBJECTIVE

To assess genital tract sepsis-related maternal mortality in The Netherlands during 1983-1992.

STUDY DESIGN

A nationwide Confidential Enquiry into the causes of maternal death.

RESULTS

Genital tract sepsis-related maternal mortality during 1983-1987 was 0.11 per 100,000 live births (1/893,998) and 0.93 per 100,000 live births (9/968,990) during 1988-1992. The relative risk of dying due to sepsis in the second 5-year period as compared to the first period was 10.1 (1/72 versus 9/72 maternal deaths; 95% CI 1.3-82.3; P < 0.01).

CONCLUSIONS

Also in The Netherlands an increase of death due to genital tract sepsis has been observed since the 1980s.