The return of life-threatening puerperal sepsis caused by group A streptococci

How could we suspect life-threatening perinatal group A streptococcal infection?

AIM

Perinatal group A streptococcal infection is a rare but life-threatening condition. Few reports have focused on its clinical characteristics and how to prevent deterioration. We report our experience with two antenatal fatal cases and reviewed 96 cases in the literature to assess the clinical characteristics of group A streptococcal infection.

METHODS

English-language clinical reports of antenatal and postnatal group A streptococcal infection in 1974-2019 were retrieved and examined. Relationships between clinical characteristics and maternal outcomes were assessed.

RESULTS

Univariate analysis revealed that antenatal group A streptococcal infection was significantly associated with an age of ≤19 or ≥ 35 years, cesarean section, sore throat as an initial symptom, positive throat culture, maternal death and fetal death. Multivariate analysis revealed that antenatal onset (odds ratio = 7.922, 95% confidence interval = 1.297-48.374; P = 0.025) and a quick sepsis-related organ-failure assessment score (qSOFA; low blood pressure, high respiratory rate or altered mental status) of ≥2 (odds ratio = 6.166, 95% confidence interval = 1.066-35.670; P = 0.042) were significantly related to maternal death.

CONCLUSION

Per our findings, antenatal group A streptococcal infection was significantly associated with maternal and fetal death. Further, the antenatal infection was revealed as a more critical risk factor. We suggest that the presence of any sign related to the qSOFA is a potential clue suspecting perinatal group A streptococcal infection in primary obstetric facilities.

Maternal sepsis

Maternal sepsis is "a life-threatening condition defined as an organ dysfunction caused by an infection during pregnancy, delivery, puerperium, or after an abortion," with the potential to save millions of lives if a proper approximation is made. Undetected or poorly managed maternal infections can lead to sepsis, death, or disability for the mother, and an increased likelihood of early neonatal infection and other adverse outcomes. Physiological, immunologic, and mechanical changes that occur in pregnancy make pregnant women more susceptible to infections than nonpregnant women and may obscure signs and symptoms of infection and sepsis, resulting in a delay in the recognition and treatment of sepsis. Prioritization of the creation and validation of tools that allow the development of clear and standardized diagnostic criteria of maternal sepsis and septic shock, according to the changes inherent to pregnancy, correspond to highly effective strategies to reduce the impact of these conditions on maternal health worldwide. After an adequate diagnostic approach, the next goal is achieving stabilization, trying to stop the progression from sepsis to septic shock, and improving tissue perfusion to limit cell dysfunction. Management protocol implementation during the first hour of treatment will be the most important determinant for the reduction of maternal mortality associated with sepsis and septic shock.

Streptococcal toxic shock syndrome occurring in the third trimester of pregnancy: A case report

Group A streptococcal (GAS) toxic shock syndrome (TSS) is a rare life-threatening illness. Most reported cases have occurred in the post-partum period. Here, we report a rare case of a primigravid who developed GAS TSS in the third trimester. We also review the potential preventive measures and treatment modalities for this syndrome. A 29-year-old primigravid presented at 36 weeks' gestation with diarrhea, abdominal pain, fever, and fetal bradycardia. She underwent an emergency cesarean section and was subsequently diagnosed with GAS TSS. She had a complicated post-partum course marked by a 3-month hospital stay and major sequelae. Her infant died on post-partum day 4. GAS TSS should be considered in the differential diagnosis of pregnant patients presenting with fever and rapid onset of septic shock. A consideration to treat GAS that is detected incidentally during routine screening for group B streptococcus is suggested.

Puerperal group a streptococcal infections: a case series and discussion

Puerperal group A streptococcal infections, a major postpartum killer during the late 19th and early 20th centuries, have become (fortunately) rare. We describe a cluster of 4 serious peripartum group A streptococcal infections occurring within the past five years at a single medical center. These cases were not epidemiologically linked and serve to illustrate the continuing risk of these potentially fulminant infections.

Group a streptococcal diseases and their global burden

Group A streptococcus (GAS) or Streptococcus pyogenes has been recognised as an important human pathogen since early days of modern microbiology, and it remains among the top ten causes of mortality from an infectious disease. Clinical manifestations attributable to this organism are perhaps the most diverse of any single human pathogen. These encompass invasive GAS infections, with high mortality rates despite effective antimicrobials, toxin-mediated diseases including scarlet fever and streptococcal toxic shock syndrome, the autoimmune sequelae of rheumatic fever and glomerulonephritis with potential for long-term disability, and nuisance manifestations of superficial skin and pharyngeal infection, which continue to consume a sizable proportion of healthcare resources. Although an historical perspective indicates major overall reductions in GAS infection rates in the modern era, chiefly as a result of widespread improvements in socioeconomic circumstances, this pathogen remains as a leading infectious cause of global morbidity and mortality. More than 18 million people globally are estimated to suffer from serious GAS disease. This burden disproportionally affects least affluent populations, and is a major cause of illness and death among children and young adults, including pregnant women, in low-resource settings. We review GAS transmission characteristics and prevention strategies, historical and geographical trends and report on the estimated global burden disease attributable to GAS. The lack of systematic reporting makes accurate estimation of rates difficult. This highlights the need to support improved surveillance and epidemiological research in low-resource settings, in order to enable better assessment of national and global disease burdens, target control strategies appropriately and assess the success of control interventions.

Group a streptococcal puerperal sepsis: historical review and 1990s resurgence

There appears to be a resurgence of puerperal sepsis due to a historically important pathogen, group A β-hemolytic streptococcus.

Streptococcal A infection: reemerging and virulent

Streptococcal A infections are reemerging as a dangerous clinical problem. This particular infection is usually a problem for the postpartum mother and not usually associated with fetal or neonatal infections. Maternal morbidity and mortality are overwhelming when compared with other maternal infections. Historically, group A streptococcus was the cause of epidemic postpartum sepsis prior to the advent of proper hand-washing techniques. Currently, transmission can occur directly from a colonized healthcare provider, other patients, or a community-acquired source. The Joint Commission and the International Surviving Sepsis Campaign have placed patient safety and early recognition and treatment of sepsis as major initiatives to improving patient outcomes.

Hypoplastic left heart syndrome: Rheumatic heart disease of the fetus?

Hypoplastic left heart syndrome (HLHS) accounts for nearly 25% of deaths among neonates with congenital heart disease. The essential feature of HLHS is a small left ventricle (LV) incapable of supporting the circulation. The etiology of HLHS is unknown. A hypothesis is proposed implicating an immune mechanism involving maternal antibodies produced in response to pharyngitis caused by group A beta-hemolytic streptococci (GABHS) ("strep throat"). After crossing the placenta, the antibodies injure the developing fetal heart, leading to HLHS either because of direct injury to the LV or secondary to reduced blood flow through affected aortic and mitral valves. Analogy is drawn to rheumatic heart disease (RHD), a known sequela of strep throat. In RHD a misdirected immune response originally intended for GABHS leads to cardiac injury through "molecular mimicry"; the normal heart antigens supposedly mimic the GABHS antigens. A similar pathogenesis is proposed for HLHS and related heart defects. HLHS may represent an extreme form of injury, while a milder insult may present as only mild aortic stenosis or a bicuspid aortic valve, conditions with wide prevalence among the general population. The injury may indeed superimpose on many other congenital heart defects, leading to a variable presentation of these other diseases. Beside remarkable likenesses between HLHS and RHD, the hypothesis is also supported by increasing evidence for the role of deleterious transplacental antibodies in the pathogenesis of other fetal diseases. Implications for other congenital heart diseases and the broader picture of global public health are discussed.

Group A Streptococcal Puerperal Sepsis with Retroperitoneal Involvement Developing in a Late Postpartum Woman: Case Report

Group A beta-hemolytic streptococci cause a wide range of infectious diseases such as pharyngitis, impetigo, rheumatic fever, and even septic shock. Group A streptococcal puerperal sepsis is uncommon today, but recent reports indicate a reemergence of virulent strains can cause toxic-mediated shock and multiple organ failure. We present a case report of a 29-year-old postpartum woman after cesarean section who presented group A streptococcal puerperal sepsis. Furthermore, we discuss the GAS strain in this patient and its relation with close contact among family members. The group A streptococci (GAS) were isolated from the patient's retroperitoneal fluid and from her husband's throat swab, respectively. Both isolates were shown to be identical: M type 1. It is well known that exotoxin A produced by M1 or M3 serotypes of the organisms plays a crucial role in streptococcal toxic shock syndrome (STSS). We conclude that in this patient, close contacts of persons with GAS appear to be at risk for colonization with identical strains of STSS-causing GAS such as M1 or M3 serotypes. Therefore, the appropriate antibiotic including antibiotic prophylaxis for close contact should be considered.

CovS inactivates CovR and is required for growth under conditions of general stress in Streptococcus pyogenes

The gram-positive human pathogen Streptococcus pyogenes (group A streptococcus [GAS]) causes diseases ranging from mild and often self-limiting infections of the skin or throat to invasive and life-threatening illnesses. To cause such diverse types of disease, the GAS must be able to sense adverse environments and regulate its gene expression accordingly. The CovR/S two-component signal transduction regulatory system in GAS represses about 15% of the GAS genome, including many genes involved in virulence, in response to the environment. We report that CovR is still able to repress transcription from several promoters in the absence of the putative histidine kinase sensor for this system, CovS. We also show that a phosphorylation site mutant (D53A) of CovR is unable to repress gene expression. In addition, we report that a strain with a nonpolar mutation in CovS does not grow at a low pH, elevated temperature, or high osmolarity. The stress-related phenotypes of the CovS mutant were complemented by expression of covS from a plasmid. Selection for growth of a CovS mutant under stress conditions resulted in isolation of second-site mutations that inactivated covR, indicating that CovR and CovS act in the same pathway. Also, at 40 degrees C in the wild-type strain, CovR appeared to be less active on the promoter tested, which is consistent with the hypothesis that it was partially inactivated by CovS. We suggest that under mild stress conditions, CovS inactivates CovR, either directly or indirectly, and that this inactivation relieves repression of many GAS genes, including the genes needed for growth of GAS under stress conditions and some genes that are necessary for virulence. Growth of many gram-positive bacteria under multiple-stress conditions requires alteration of promoter recognition produced by RNA polymerase association with the general stress response sigma factor, sigma(B). We provide evidence that for GAS, which lacks a sigB ortholog, growth under stress conditions requires the CovR/S two-component regulatory system instead. This two-component system in GAS thus appears to perform a function for which other gram-positive bacteria utilize an alternative sigma factor.

Group A streptococcal toxic shock syndrome developing in the third trimester of pregnancy

BACKGROUND

Group A streptococcal (GAS) toxic shock syndrome (TSS) is an uncommon, but life-threatening infection during pregnancy and should be considered in rapid onset of shock. Most cases described in the literature have occurred in the puerperium. We report a case of GAS TSS occurring during the third trimester of pregnancy in a previously healthy woman.

CASE

A 31-year-old female, who was 34 weeks pregnant, presented with fevers and a prodromal 'flu-like' illness. She rapidly developed shock and multiorgan failure. Blood cultures revealed GAS bacteremia and the patient met criteria for streptococcal TSS. Despite her eventual recovery, her infant died on postpartum day 15 as a consequence of the mother's TSS.

CONCLUSIONS

This case is unusual in that there were no identifiable initiating events or source of the streptococcal infection, and the TSS developed during pregnancy rather than after delivery. Early recognition of GAS infections is important given the rapid onset and high morbidity and mortality associated with these infections. This is the first reported case utilizing intravenous immunoglobulin for GAS TSS in the puerperium.

Septic shock resulting in death after operative delivery

BACKGROUND

We report a young woman who developed septic shock after operative delivery in the 32nd week of pregnancy. Clinical features, treatment modalities and prognosis of this high-mortality-rate disorder are presented and discussed.

CASE

A 24-year-old woman, gravida 1, para 1, was referred to our clinic in a confused state and immediately admitted to our emergency unit. She apparently had eclampsia antenatally. Termination of pregnancy with induction of labor and vacuum extraction had been employed in gestational week 32 of pregnancy. One day after delivery, her clinical and laboratory parameters worsened, so she was referred to our clinic. After a thorough physical examination and laboratory evaluation, the patient was diagnosed as having sepsis and disseminated intravascular coagulation. After blood and urine cultures were taken, aggressive management included volume repletion, antibiotics and positive inotropic therapy. Because she had persistent fever and unimproved laboratory values despite these therapies, the uterus and ovaries were thought to be the source of sepsis, and total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Neither clinical nor laboratory parameters improved, and the patient died 28 days after delivery as a result of respiratory failure.

CONCLUSION

It is our purpose to emphasize that a rapid and appropriate decision for surgery may prevent the maternal mortality in obstetric septic shock patients. Successful management depends on early identification and aggressive treatment.

Semmelweis: the combat against puerperal fever

Groups A and B streptococci are of great significance in the history of obstetrics. Group A streptococci were a great threat to the puerperium, especially in the 19th century, when homebirth was replaced by institutional birth in lying-in hospitals. The history of the rise and fall of puerperal fever is indeed a tragedy. Some people, like Semmelweis, who brought new and important evidence based findings were not believed by their fellow obstetricians, an attitude that spoiled thousands of innocent lives. Even today group A streptococci, though seldom, may be the cause of puerperal sepsis. Group B streptococci are widespread and may cause sepsis and important lifelong morbidity or mortality of the newborn. Obstetricians today try to establish cost-effective prophylactic measures during labor to prevent these neonatal infections.

Vaginal-rectal colonization with group A streptococci in late pregnancy

OBJECTIVE

To determine the vaginal-rectal colonization rate with group A streptococci in late pregnancy.

METHODS

All patients delivering at a northern New England hospital over a 38 month period had 35-37 week vaginal-rectal swabs cultured for group A and group B streptococci, using selective media and slide agglutination.

RESULTS

Six thousand nine hundred forty-four screening cultures were obtained. Among these 1,393 were positive for group B streptococci and 2 for group A streptococci, yielding colonization rates of 20.1% and 0.03%, respectively.

CONCLUSIONS

Vaginal-rectal colonization with group A streptococci is rare, arguing against the need for establishing group A streptococcal screening programs in pregnancy. An approach for managing this uncommon finding is presented.

Puerperal and intrapartum group A streptococcal infection

OBJECTIVE

To determine the demographic and clinical variables characteristic of non-epidemic intrapartum or puerperal group A streptococcal (GAS) infection.

METHODS

The records of 47 patients diagnosed with intrapartum or puerperal GAS infection over a 6 1/2 year period at Hadassah-University Hospital-Mt. Scopus, Jerusalem were reviewed. Data regarding 25,811 women, the general population of women that delivered during that period, were obtained from their computerized medical records. Frequency distributions, t-test, chi-square, and Spearman's Rank Correlation were used, as appropriate, to analyze and compare demographic and clinical variables associated with development of GAS infection, its clinical course and subsequent development of septic shock.

RESULTS

Mean age of mothers with GAS infection was higher than that of our general pregnant population (30.4 versus 27.4 years, P = 0.0019), and a higher proportion of GAS infected patients (30% versus 12%, P < 0.005) experienced PROM. Thirty-one (66%) women had fever as their sole presenting symptom, eight (17%) had fever and abdominal pain, seven (15%) had fever and abnormal vaginal bleeding, and one patient (2%) presented with a rash. Three patients (6%) developed a septic shock. Two of these patients presented with symptoms more than 14 days after delivery.

CONCLUSIONS

We describe the characteristics of non-epidemic intrapartum or puerperal GAS infection. Data from our study and review of the literature suggest that some patients who develop septic shock may present later in the puerperium than patients with an uncomplicated GAS infection.

Streptococcal toxic shock syndrome in a postpartum woman. Case report and review of the literature

A case of streptococcal toxic shock syndrome in a 29-year-old postpartum woman is described. The patient presented with hypotension, coagulation defects, adult respiratory distress syndrome and scarlet exanthema as a complication of hemolytic group A streptococcal endometritis. One hundred and twenty-two other cases of streptococcal toxic shock syndrome in the literature are reviewed and the criteria of the syndrome discussed. Streptococcal toxic shock syndrome seems to be increasing along with more frequent invasive streptococcal infections in several countries. It is therefore important to recognize and treat the infection as early as possible to minimize the risk of mortality.