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Adult Group B Streptococcal Disease
- Douglas C. Waite, MD;
- Eric J. Alper, MD; and
- Brian J. Mady, MD
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TO THE EDITOR:
Group B streptococci account for less than 1% of organisms causing meningitis in adults and are seen in immunocompromised and immunocompetent hosts [1]. Persons infected with the human immunodeficiency virus (HIV) have a risk for invasive group B streptococcal infection 30 times greater than that seen in persons without HIV infection [2]. We report the first case of group B streptococcal meningitis in a patient with HIV infection who had had splenectomy.
A 39-year-old HIV-positive man with a CD4 count of 1100 cells/mm3 who had had splenectomy 10 years earlier presented with a 2-day history of fever and chills, bitemporal headache, a 1-day history of left knee and ankle pain, and urethral discharge with dysuria. Remarkable physical findings included toxic appearance, a temperature of 38.4 °C, nuchal rigidity, and left knee and ankle swelling with decreased range of motion. The patient was immediately given intravenous ceftriaxone.
The patient's leukocyte count was 12 900 cells/mm3 (69% neutrophils and 21% bands). Examination of cerebrospinal fluid obtained 2 hours after administration of antibiotic agents showed cloudy fluid with 5000 leukocytes/mm3 (94% neutrophils and 3% bands), 500 erythrocytes/mm3, a protein level of 435 mg/dL, and a glucose level less than 1 mg/dL. A Gram stain showed gram-positive intracellular bacilli, and latex agglutination was positive for group B streptococcal antigen. The synovial fluid from the left knee contained 900 leukocytes/mm3 (36% neutrophils, 3% bands, and 64% mononuclear cells). No organisms were seen on the Gram stain.
The patient began receiving cefotaxime, vancomycin, and ampicillin. His fever resolved within 12 hours, and he had increased mobility of his left knee. At 24 hours, three sets of blood cultures and a urethral culture were growing group B streptococci. Antibiotic therapy was changed to penicillin. The cerebrospinal and synovial fluid cultures remained sterile. The patient was treated with a 2-week course of penicillin and recovered without sequelae.
We are confident in our diagnosis of group B streptococcal meningitis, given the patient's clinical presentation, cerebrospinal fluid profile, positive blood and urethral cultures, and positive cerebrospinal fluid latex agglutination result. The negative cerebrospinal fluid culture and atypical Gram stain may be explained by previous antibiotic administration. Group B streptococci can colonize the urethra [3], and we suspect that this was the source of the dissemination. Overwhelming group B streptococcal infection has been described in five patients who had had splenectomy; none of these patients, however, had meningitis [4]. We believe that our patient's HIV infection (and possibly his asplenia) predisposed him to group B streptococcal meningitis. This case and the work by Farley and colleagues [1] should heighten awareness of group B streptococcal disease in HIV infection. We agree with Jackson and colleagues [5], who support the development of a group B streptococcal vaccine for use in patients at highest risk for invasive infection.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
