Disseminated Group G Streptococcus mimicking systemic vasculitis with skin, lung, and eye manifestations:  A Case Report.

Abstract

Background: Group G streptococcal species can represent normal human flora as asymptomatic colonization. In the setting of infection, group G streptococcus can invade multiple structures and present broadly including bacteremia, toxic shock syndrome, endocarditis, septic arthritis, osteomyelitis, necrotizing skin infections, pharyngitis, and others. Severe cases tend to be more common in patients of increasing age or with chronic illnesses. Here we report a case of disseminated group G streptococcus mimicking systemic vasculitis. Case Presentation: A 41-year-old white male was hospitalized with a five-day history of fevers, chills, painful bilateral leg rash, generalized arthralgias, and right eye redness, pain and severe vision loss. Medical history was significant for minimal change disease treated with prednisone and cyclosporine. On admission, he was noted to be cushingoid with edematous erythema at the left hand, and bilateral lower limb rash. The right eye was inflamed with hypopyon. Laboratory studies demonstrated mild leukocytosis, modest thrombocytopenia, hyponatremia, hyperglycemia, with elevated CRP and creatinine. Urinalysis was positive for proteinuria, microscopic hematuria, and pyuria. CT chest demonstrated right upper lobe consolidation. There was concern for systemic vasculitis and cellulitis of the left hand. Intravenous methylprednisolone and empiric antibiotics were initiated. Ophthalmology was consulted for right uveitis and aspirated fluid from the anterior chamber. Dermatology biopsied the lower limb rash and identified leukocytoclastic vasculitis. Pulmonology performed bronchoscopy and bronchoalveolar lavage of the right upper lobe. Prior renal pathology was re-reviewed. Rheumatology was consulted due to suspicions for systemic vasculitis. Lancefield group G streptococcus was ultimately cultured from multiple blood samples, bronchoalveolar lavage fluid and right eye aspirate. There was no evidence of endocarditis on imaging. It was concluded that the source of the bacteremia and disseminated infection was most likely the left-hand cellulitis. Conclusions: To our knowledge, we present the first case of disseminated Group G streptococcal infection presenting with the constellation of bacteremia, endophthalmitis, focal mass-like lung consolidation, and leukocytoclastic vasculitis of lower extremities. The multi-organ distribution mimicked a systemic small vessel vasculitis. This case highlights the importance of infectious etiologies in the differential diagnosis of vasculitis – especially in the setting of infectious risk factors.