Streptococcus agalactie involved in the etiology of Sexually Transmitted Diseases

Abstracts

O Streptococcus agalactie é um importante micro-organismo causador de doenças em gestantes, neonatos, idosos (maiores de 65 anos de idade), e portadores de doenças crônicas debilitantes, sendo um patógeno incomum em pacientes que não se enquadrem nestas faixas etárias ou perfil clínico (1-5), e, raramente, é descrito como agente causador de doenças sexualmente transmissíveis. Descrevemos o caso de um adulto jovem hígido de 19 anos, apresentando lesões ulceradas genitais e oral, assim como corrimento uretral e ocular, sugestivas de terem sido causadas pelo Streptococcus agalactie, e adquiridas através do contato sexual (doenças sexualmente transmissíveis).

Doenças sexualmente transmissíveis; Streptococcus agalactiae; Uretrite; Úlcera cutânea

CASE REPORT

Marcos Noronha Frey^I; Ana Elisa Empinotti Ioppi^II; Renan Rangel Bonamigo^III; Guilherme Pinheiro Prado^IV

^IDermatologist. Medical degree awarded by the Fundação Faculdade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, RS, Brazil

^IIPhysician undergoing specialization training in dermatology. Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, RS, Brazil

^IIIPhD in Medical Sciences awarded by the Federal University of Rio Grande do Sul (Universidade Federal do Rio Grande do Sul). Professor of dermatology and professor of the postgraduate program in pathology, Universidade Federal de Ciências da Saúde de Porto Alegre. Head, department of dermatology, Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, RS, Brazil

^IVMedical student, Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, RS, Brazil

Mailing address

ABSTRACT

Streptococcus agalactiae is an important microorganism involved in a number of conditions in pregnant women, newborns, elderly people (over 65 years of age) and individuals with chronic disabling illnesses. This pathogen is infrequently found among patients outside this age range or clinical profile(1-5) and is rarely reported in the etiology of sexually transmitted diseases. Here we describe a case of an otherwise healthy 19 year-old male, who presented with ulcerative genital and oral lesions in association with urethral and ocular discharge, suggestive of Streptococcus agalactiae infection acquired through sexual contact.

Keywords: Oral ulcer; Sexually transmitted diseases; Skin ulcer; Streptococcus agalactiae; Urethritis

INTRODUCTION

The only representative of group B streptococcus (GBS), the Streptococus agalactie, is an important microorganism that causes diseases in pregnant women, neonates, the elderly (older than 65 years of age), and carriers of debilitating chronic diseases; it is an uncommon pathogen outside of these age groups or clinical profile. ^1-6 The present study describes the case of a healthy young man with lesions on the genitals and in the oral cavity, probably transmitted by sexual contact, caused by GBS.

CASE REPORT

A 19-year-old male patient presented with complaints of generalized malaise, dysuria, diffuse myalgia, arthralgia (affecting mainly the finger, hand and wrist articulations) as well as painful lesions on the penis, that appeared 5 days after unprotected sexual contact (vaginal intercourse and oral sex) with an unknown partner. Concomitantly with the onset of genital lesions, he noticed a painful lesion in the oral cavity. The physical examination revealed several ulcerative lesions, with 2-3 mm diameter, shallow and exudative (a fetid yellow-green secretion), located on the glans, the foreskin and pubis, close to the penis, associated with small mobile painful adenomegaly in the bilateral inguinal region (Figure 1). The urethral examination showed moderate meatal erythema (without edema), with urethral drainage of thick and scarce greenish secretion. The oral cavity examination revealed a single ulcerative lesion, shallow, with 1 cm diameter, located posteriorly to the last right molar, with the presence of exudative thick yellow-green material, very painful to the touch (Figure 2). The articular examination did not show signs of fever, but only slight local pain on palpation. Laboratory exams of serum, urine and secretions of mucous-cutaneous and urethral ulcers (swabs) were carried out, with the following results: the hemogram was within normal values, the urine sediment presented hemoglobin 2 ++ and leukocytes 9-10 cells/field, urine culture negative, VDRL and serology for Syphilis IgM and IgG (ELISA) were non-reactive, anti-HIV nonreactive and serology for Chlamydia trachomatis IgM was non-reactive. Previously to the bacteriological results, in view of the genital ulcers and urethral drainage, the patient was empirically treated with oral azithromycin 1g associated with a single dose of intramuscular ceftriaxone 250mg (according to the syndromic approach recommended by the Ministry of Health).⁷ The patient evolved with progressive improvement of lesions and symptoms, with complete remission of the symptom complex after two months of treatment. As regards the bacteriological results (Gram and culture) of the urethral secretion, penile ulcers and oral ulcer, Grampositive cocci were found in all sites, as well as an isolated single germ of the Streptococcus agalactie type in the cultures (chocolate agar medium for the urethral secretion and blood agar medium for genital and oral ulcer secretions, positive CAMP test), all with the same antibiogram profile (sensitive to penicillin, clindamycin, erythromycin, vancomycin and chloramphenicol). Considering the bacteriological findings, laboratory tests and clinical response to the treatment prescribed, it was decided not to begin another antimicrobial scheme but just do the clinical and laboratory follow-up. Four weeks after the end of treatment, the patient had not presented new lesions or positive serologies (VDRL and anti-HIV), being lost to follow-up after this period.

DISCUSSION

Only a few cases of Streptococcus agalactie as the causative agent of urethritis, genital and oral ulcers were found in the worldwide literature. It is known that this pathogen is a possible agent of skin and soft tissue infections, and that its preference is for extreme age groups (neonates until the first week of life and the elderly above 65 years of age), pregnant women during delivery and those chronically debilitated (such as diabetics and carriers of malignant neoplasms), and that it is rarely found outside of this patient profile.^1-5 It can colonize between 20-35% of the population (generally isolated in rectum, perineum, vagina, cervix and urethra cultures), with greater prevalence in sexually active individuals and in those with multiple sex partners, suggesting that it is acquired by sexual contact.¹

As regards cutaneous affection, it is important to remember that GBS is statistically surpassed by group A Streptococcus (GAS).² The infections that are typically related to GBS are erysipelas/cellulites and wound and ulcer infections. More rarely, we also find necrotizing fasciitis and the toxic shock syndrome. In up to one third of cases, these infections are polymicrobial, with the Staphylococcus aureus as the most frequently co-involved germ.^1-4

Oral ulcers such as that described in this case were not found in the literature. As for the genital ulcers, we found only one report described by James⁽³⁾, in 1984. Regarding GBS as a microorganism causing urethritis, there is little information in the literature, with a reported estimated prevalence of 1.5% of cases among urethrites of non-gonococcal origin. ⁶ It is also estimated that GBS is found in around 3.4% of urine cultures of female patients that are known carriers of lower urinary tract infections, with a smaller percentage in male patients.⁸

The role of Streptococcus agalactie as causing agent of sexually transmitted diseases (STDs) is still controversial.^9,10 Its characteristics suggest that it may have an opportunistic behavior, and that the presence of immunological frailty may be necessary for the microorganism to find conditions to develop some kind of disease. In the opinion of the authors, the data collected in the patient's anamnesis and related to the clinical and laboratory findings suggest that this is a case of STD caused by Streptococcus agalactie.

REFERENCES

• 1. Sendi P, Johansson L, Norrby-Teglung A. Invasive group B streptococcal disease in non-pregnant adults: a review with emphasis on skin and soft-tissue infections. Infection. 2008;36:100-11.
• 2. Craft N, Lee PK, Zipoli MT, Weinberg AN, Swartz MN, Johnson RA. Superficial cutaneous infections and pyodermas. In: Wolff K, Goldsmith LA, Katz ST, editors. Fitzpatrick's Dermatology in General Medicine. 7 th ed. New York: Mc Graw Hill; 2008. p. 1694-709.
• 3. James MAJWD. Cutaneous group B streptococcal infection. Arch Dermatol. 1984;120:85-6.
• 4. Schuchat A. Group B streptococcus Lancet. 1999;353:51-6.
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• 6. Tiodorović J, Randelović G, Kocić B, Tiodorović-Zivković D. Bacteriological finding in the urethra in men with and without non-gonococcal urethritis. Vojnosanit Pregl. 2007;64:833-6.
• ⁷
  Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e AIDS. Manual de Controle das Doenças Sexualmente Transmissíveis. Série Manuais n. 68. 4. Ed. Brasília: Ministério da Saúde; 2006. 140 p.
• 8. González-Pedraza A, Ortiz C, Mota R, Dávila R, Dickinson E. Papel de las bacterias asociadas a infecciones de transmisión sexual en la etiología de la infección de vías urinárias bajas en el primer nivel de atención médica. Enferm Infecc Microbiol Clin. 2003;21:89-92.
• 9. Honig E, Mouton JW, van der Meijden WI. The epidemiology of vaginal colonisation with group B streptococci in a sexually transmitted disease clinic. Eur J Obstet Gynecol Reprod Biol. 2002;105:177-80.
• 10. Chowdhury MNH, Pareek SS. Urethritis caused by group B streptococci: A case report. Br J Vener Dis. 1984;60:57-6.

Streptococcus agalactie

involved in the etiology of Sexually Transmitted Diseases

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Publication Dates

• Publication in this collection
  23 Jan 2012
• Date of issue
  Dec 2011

History

• Received
  16 July 2010
• Accepted
  13 Sept 2010