Group A Streptococcus Spinal Epidural Abscess During Varicella

Abstract

ABSTRACT. Multiple complications of varicella have been described. Musculoskeletal complications (osteomyelitis, septic arthritis, and necrotizing fasciitis) as well as neurologic complications (ataxia, encephalitis, and transverse myelitis) are well-known. We describe the cases of 2 children, ages 18 months and 5 years, who were admitted recently to 2 pediatric hospitals in Montreal with a resolving varicella, abdominal and lumbar pain, and a refusal to walk and in whom a diagnosis of epidural abscess caused by group A streptococcus (GAS) was established. No previous case of epidural abscess caused by GAS in the context of varicella has been reported. Epidural abscesses are rare in pediatrics and are caused mainly by hematogenous spread of Staphylococcus aureus. The diagnosis in pediatrics is challenging because it is rare and does not present as classically as in adults. The prognosis is related to the presence of neurologic deficits before surgery and to the rapidity with which the diagnosis and the intervention are made. These cases highlight a new clinical association in children of epidural abscess caused by GAS and varicella. V aricella is a common childhood viral illness, with a projection of 380 000 cases annually in Canada, approaching the annual birth rate. 1 The estimated risk of hospitalization is approximately 1 in 550 cases. 2 Multiple complications from varicella have been described. The majority of these consist of secondary skin and soft tissue bacterial infections ranging from 45% to 73% of the reported complications caused mainly by group A ␤-hemolytic streptococcus (GAS) and Staphylococcus aureus. 2,3 Neurologic complications (18%-21%), such as encephalitis, postinfectious cerebellar ataxia, Reye syndrome, aseptic meningitis, and transverse myelitis, have also been reported. 2,4,5 Musculoskeletal complications mostly attributable to GAS (osteomyelitis, necrotizing fasciitis, myositis, and septic arthritis) are well-described, 6 but no previous case of spinal epidural abscess (SEA) has been found in the literature. We describe 2 cases of children with a diagnosis of SEA as a complication of varicella. CASE 1A previously healthy 1 1 ⁄2-year-old boy presented with fever up to 40°C for 4 days and refusal to sit or walk for 3 days. He had developed varicella 6 days before the onset of fever and had a mild case until then. His mother had received a diagnosis of streptococcal pharyngitis the week before admission. On examination, he was irritable. There was no evidence of secondary bacterial superinfection of the skin and soft tissues. He had a stiff neck and bilateral brisk patellar deep tendon reflexes, clonus, and positive Babinski sign. The muscular strength was normal. His peripheral white blood cell (WBC) count was 14.8 ϫ 10 9 /mm 3 . A lumbar puncture yielded clear cerebrospinal fluid (CSF) containing 50 WBC/mm 3 , 4.3 mmol/L glucose, and 13.4 g/L proteins. Gram stain and culture of the CSF were negative. Intravenous therapy with cefotaxime and vancomycin was started. A throat culture done b...

Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature

“…2 The most common organism causing pediatric SEA is S aureus. 2,4,7,9,11,12,16,17,[19][20][21][22] There is increasing prevalence of community-acquired MRSA infections in children without risk factors. 23,24 A thorough literature review performed by Auletta et al indicates high rates of methicillin-sensitive S aureus, in contrast to our review in which the 6 culturepositive patients grew MRSA, reinforcing the changing prevalence and invasiveness community-acquired MRSA can display.…”

“…3,8 The length of time before initiation of treatment and the severity of neurologic deficit are the 2 factors most predictive of outcome. 1,5,9,20 There is less neurologic recovery with prolonged neurologic deficit before initiation of therapy; paralysis for .24 hours is commonly irreversible. 14,26 Although data are limited, children tend to have improved outcomes compared with adults.…”

Group A Streptococcal Subdural Empyema as a Complication of Varicella

“…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. …”

Axillary Abscess Complicated by Venous Thrombosis: Identification ofStreptococcus pyogenesby 16S PCR

“…Abscess formation at other sites occurs rarely. Cases of abscesses with S. pyogenes in the brain (6,7,9,17), in the epidural space (10,16), in the mediastinum (5), in the lung (8), in the spleen (4), in the retroperitoneum (11), in the pericolic tissue (15), in muscular tissue (1,3,18), and in periprosthetic breast tissue (14) have been reported. Considering how common S. pyogenes infections are, abscess formation at sites other than those around the tonsils is distinctly uncommon.…”