Group A Streptococcal Subdural Empyema as a Complication of Varicella

Abstract

ABSTRACT. Group A ␤-hemolytic streptococcus and Staphylococcus aureus are the 2 most common pathogens implicated in secondary invasive bacterial disease after varicella. We describe a 3-month-old male infant from British Columbia, Canada, who presented on day 5 of varicella skin rash with fever, seizures, lethargy, and evidence of intracranial hypertension. A prominent subdural empyema was documented, and Streptococcus pyogenes was recovered from the subdural fluid. Central nervous system bacterial complications should be part of the differential diagnosis for infants and children with chickenpox who present with fever, lethargy, focal seizures, or similar neurologic findings. This case illustrates the importance of universal varicella vaccination to prevent associated bacterial complications of chickenpox. T he clinical course of varicella in childhood is usually benign and self-limited. However, secondary bacterial complications can occur in skin, soft tissues, and other sites, caused predominantly by group A streptococcus (GAS) and Staphylococcus aureus. 1 For varicella-associated, invasive, suppurative complications, the former is associated with increased morbidity and mortality rates among both immunocompetent and immunosuppressed children, and episodes can occur even without an obvious skin source of infection. Among children, GAS infections of the central nervous system (CNS) and peripheral nervous system after chickenpox are extremely rare. [2][3][4] We describe an infant who developed a GAS subdural empyema during varicella, which is, to our knowledge, an association not described previously. CASE REPORTA 3-month-old boy was admitted to a community hospital, on day 5 of a varicella skin rash, with fever and focal seizures. On day 1 of the rash, the patient developed decreased appetite and vomited twice; the following day, he began to exhibit a fever of 39°C. On day 4, he was examined at a primary care clinic, a diagnosis of acute otitis media (AOM) was made, and treatment with orally administered trimethoprim-sulfamethoxazole was initiated (the patient received a total of 2 doses). On day 5, the patient was described by his parents as being irritable and lethargic, and that night he developed right-sided focal seizures of the face, arm and leg, with subsequent ocular deviation. The seizures persisted, became generalized, and led to status epilepticus, which necessitated repeat doses of intravenously administered diazepam and phenytoin after admission to the local hospital. The body temperature was 37.8°C, a diffuse varicella skin rash with no evidence of secondary bacterial infection was described, and no AOM was observed. The patient underwent head computed tomography, which showed bilateral subdural fluid collections with left-sided predominance, with a compressed ventricular system and mild midline deviation. A clinical diagnosis of varicella encephalitis and subdural effusions was made, blood cultures were obtained, 1 dose of acyclovir was administered intravenously, and the patient was transferred...

Streptococcal pharyngitis: an uncommon cause of subdural empyema

“…The portal of entry for invasive group A streptococcal disease (GAS) disease remains undetermined for about one-fourth of S. pyogenes 2. In the same review, among children and adults with confirmed GAS meningitis, two children were found to have brain abscess, two had subdural hygromas and none had SDE 2. From our literature search, we found no cases of SDE resulting from S. pyogenes originating from an acute pharyngeal infection.…”

“…Her blood, CSF and surgically evacuated fluid cultures all grew S. pyogenes , with the suspected source being streptococcal pharyngitis based on oropharyngeal examination, despite negative previous testing. Intracranial infections caused by S. pyogenes are rare and nearly always associated with significant meningitis or a contiguous focus 2 3 8. In a review of SDE and its management, S. pyogenes is listed as a source for infection for SDE only when originating from either the paranasal sinuses, otomastoiditis or acute otitis media 2.…”

“…Intracranial infections caused by S. pyogenes are rare and nearly always associated with significant meningitis or a contiguous focus 2 3 8. In a review of SDE and its management, S. pyogenes is listed as a source for infection for SDE only when originating from either the paranasal sinuses, otomastoiditis or acute otitis media 2. The portal of entry for invasive group A streptococcal disease (GAS) disease remains undetermined for about one-fourth of S. pyogenes 2.…”

“…In a review of SDE and its management, S. pyogenes is listed as a source for infection for SDE only when originating from either the paranasal sinuses, otomastoiditis or acute otitis media 2. The portal of entry for invasive group A streptococcal disease (GAS) disease remains undetermined for about one-fourth of S. pyogenes 2. In the same review, among children and adults with confirmed GAS meningitis, two children were found to have brain abscess, two had subdural hygromas and none had SDE 2.…”

“…In children, the usual source for SDE is direct extension from a contiguous source, such as acute sinusitis or otitis media,1 although in one-fourth of cases no source of infection is found 2. The usual causal organisms are anaerobes, aerobic streptococcal species, staphylococci, Haemophilus influenzae and other Gram-negative bacilli 1.…”