253 KUWAIT MFnIC\1 JOURNAl September 2016

Case Report

Cellulitis and Sepsis Caused by Group AStreptococcus in Saudi Neonate: Case Report

Badr Hasan Sobaih, Adrian HadidDepartment of Pediatrics, NICU , King Saud University, King Khalid University Hospital, Saudi Arabia

Kuwait Medical Journal 2016; 48 (3): 253 - 254

ABSTRACT----------------------------------------------------------

We report a 40 day-old infant with late onset groupA cellulitis and sepsis presented with fever and neckswelling with redness and tenderness. He was seriouslyaffected and ventilated. Group A streptococcus (GAS)was isolated from blood within 24 hours. He was

dramatically improved with proper antibiotics anddischarged home in good condition. Mother washealthy. We believe that the source of GAS was one ofhis brothers with tonsillitis, but no evaluation was doneto confirm it.

KEY WORDS: cellulitis, group a streptococcus, neonatal

INTRODUCTIONA Streptococcal sepsis caused by group A

Streptococcus is one of the major causes of neonatalinfections'!'. It can lead to serious Cellulitis and sepsis.The objective of reporting this case is to be aware of thisinfection and the need for immediate implementationof an aggressive treatment.

CASE REPORTA 40-day-old male infant was admitted to our

neonatal intensive care unit (NICU) with one dayhistory of fever (38.6 "C axillary) associated withlethargy and poor feeding after being completelyhealthy. Followed next day by rapidly progressivesubmandibular swelling with redness (Fig 1).

He was a product of 36-week pregnancy for 32years old gravida 4 para 3, healthy, Un-booked Saudilady with un-eventful pregnancy and normal ante-natal ultrasound. No history of prolonged rupture ofmembrane (PROM), delivered by normal spontaneousvaginal delivery with birth weight of 2.3 kg and normalApgar scores. He was kept at NICU for 10 days afterbirth for borderline prematurity and discharged innormal condition after receiving routine vaccination.He was breastfed and mother was healthy. One of hisbrothers had tonsillitis five days prior to admission.

Examination revealed sick-looking infant with mottledskin and diffused neck swelling with redness, warmto touch with some tenderness, and no fluctuation.The infant was sick to the extent that he requiredmechanical ventilation. Full septic screen was doneincluding cerebrospinal fluid culture and was startedon vancomycin, cefotaxime, and clindamycin pendingcultures results. C-reactive protein was very high (123mg/L). CBC showed WBC count of 10 x 109 with 72%polymorphs. CSF result was normal as well as urineculture. Blood culture showed growth of group AStreptococcus (GAS) within 24 hours of admission.GAS was sensitive to clindamycin, Penicillin G,Ampicillin, and Cephradine. The infant was shifted toPenicillin G. He showed good response to treatmentand was extubated within six days, and was eventuallydischarged home in good condition.

DISCUSSIONBefore the introduction of antibiotics, group A

streptococcal sepsis (GAS) was one of the majorcauses of neonatal infections, the incidence of whichreduced after antibiotic era!". Group B streptococciand Escherichia coli have replaced GAS as the majorcauses of neonatal sepsis since the establishment ofantimicrobial therapy'", The mortality rate of invasive

Address correspondence to:Badr Hasan Sobaih, MD, MBBS, ABP, Assistant Professor of Pediatrics, King Saud University, King Khalid University Hospita, Department ofPediatrics, NICU, PO Box: 2925, Riyadh 1146, Khlgdom of Saudi Arabia. Mobile: 966505453580; Fax: 966114672395, Emnil bad r 11 a s an saba i h@gmail.com ,drhsobaih@yahoo.com

September 2016 254KUWAIT MEDICAL JOURNAL

Fig 1: Diffuse swelling and redness on submandibular and frontal aspects of the neck

GAS disease in neonates remains high despite declinein its incidencel''. Most of the reported cases of invasiveGAS in neonates were of early onset «5 days) ratherthan late onset (>5 days)!",

The case we presented in this report was of lateonset neonatal cellulitis and sepsis caused by GAS,and we suspect that GAS was most likely acquiredfrom the child's 5-year-old brother who was sufferingtonsillitis around the period of sickness of this child.Unfortunately, we did not investigate the brother toconfirm the source of GAS in our patient. To the bestof our knowledge, this is the first case of GAS causingneonatal cellulitis reported in Saudi Arabia. In fact, itis considered as a rare presentation worldwide, withmothers as the usual source of infection-",

CONCLUSIONThe presence of neonatal cellulitis should be taken

seriously and dealt with as serious invasive diseaseof neonates that can be often associated with sepsis.Full septic workup and immediate use of intravenousbroad-spectrum antibiotics must be performed for allneonates with similar presentation of our case. GroupA streptococcus should be considered as one of the

organisms that can cause serious invasive neonatalcellulitis and sepsis since there are reported cases inthe literature. Mothers should be carefully evaluatedlooking for the source of GAS. Other members of thefamily and close contacts of neonates with GAS shouldalso be carefully evaluated by conducting properinquiries and performing proper investigations forsuspected cases.

REFERENCES

1. Murphy DJ. Group A streptococcal meningitis.Pediatrics 1983;71:1-5.

2. Freedman RM, Ingram DI, Gross I, et al. A halfcentury of neonatal sepsis at Yale. Am J Dis Child1981; 135:140-144.

3. O'brien KL, Beall B, Barrett NL, et al. Epidemiology ofinvasive group A Streptococcus disease in the UnitedStates, 1995-1999.Clin Infect Dis 2002;35:268-276.

4. Miyairi I, Berlingieri D, Protic J, et al. Neonatal invasivegroup A streptococcal disease: case report and reviewof literature. Pediatr Infect Dis J 2004;23:161-165.

5. Matric J, Mijac V, Jankovic B, et al. Neonatal cellulitisand sepsis caused by group A streptococcus. PediatrDermato12010; 5:528-530.