Perianal streptococcal cellulitis

Perianal streptococcal disease in childhood: systematic literature review

Group A Streptococcus has been associated with a perianal infection. We conducted a systematic review of the literature on childhood streptococcal perianitis in three databases: Excerpta Medica, National Library of Medicine, and Web of Science. The main purposes were to document the clinical features, the tendency to recur, the association with an asymptomatic streptococcal throat carriage, the accuracy of rapid streptococcal tests, and the mechanism possibly underlying the acquisition of this infection. More than 80% of cases are boys ≤7.0 years of age with defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness. Perianitis is associated with a streptococcal tonsillopharyngitis in about every fifth case. The time to diagnosis is ≥3 weeks in 65% of cases. Recurrences occur within 3½ months in about 20% of cases. An asymptomatic group A streptococcal throat carriage occurs in 63% of cases. As compared with perianal Streptococcus A culture, the rapid streptococcal tests have a positive predictive value of 80% and a negative predictive value of 96%. It is hypothesized that digital inoculation from nasopharynx to anus underlies perianitis. Many cases are likely caused directly by children, who are throat and nasal carriers of Streptococcus A. Some cases might occur in children, who have their bottoms wiped by caregivers with streptococcal tonsillopharyngitis or carriage of Streptococcus.Conclusion: Perianitis is an infection with a distinctive presentation and a rather long time to diagnosis. There is a need for a wider awareness of this condition among healthcare professionals. What is Known: • Group A Streptococcus may cause perianitis in childhood. • Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment. What is New: • The clinical presentation is distinctive (defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness). • The time to diagnosis is usually ≥3 weeks. Recurrences occur in about 20% of cases.

Perianal infectious dermatitis: An underdiagnosed, unremitting and stubborn condition

Perianal infectious dermatitis (PID) represents a superficial inflammation of the perianal skin, which is of bacterial origin (classically, group A beta-hemolytic streptococci). This narrative review aims to critically review and summarize the available scientific literature regarding pediatric PID, being the first of its kind, to the best of the author’s knowledge. It also reports the first cases of Romanian children with PID. Multiple databases were subjected to systematic literature search (from 1966 to April 30, 2018) to identify studies and case reports of children with PID. As such, this review provides updated information about essential aspects of PID (epidemiology, etiology, pathogenesis, as well as clinical features, required investigations and therapeutic options) and of diagnostic pitfalls. Although a well-defined entity, PID remains largely underdiagnosed. PID may mimic other common conditions with skin manifestations (like candidiasis, pinworms, eczema, irritant dermatitis, anal fissure, hemorrhoids, Crohn’s disease, psoriasis, seborrheic dermatitis, zinc deficiency dermatosis and even sexual abuse), with consequent unnecessary, sometimes expensive and invasive investigations and futile therapies, which cause patients and families discomfort and distress. Since PID has an unremitting course, early recognition is imperative, as it allows for prompt and efficacious antibiotic therapy. However, PID represents a stubborn condition and, even if properly treated, its recurrence rate remains high. Further well-designed prospective randomized controlled trials, with adequate follow-up, are required in order to formulate the optimum personalized antibiotic therapy (oral alone or in association with topical medication), able to prevent recurrences. Awareness of this condition by healthcare professionals should improve patient outcomes.

Outcomes in children treated for perineal group A beta-hemolytic streptococcal dermatitis

OBJECTIVES

To evaluate reports that describe relapse or recurrence following treatment of perineal streptococcal dermatitis (PSD), we studied a large cohort of children with these perianal or perivaginal infections to determine whether outcomes are related to the antimicrobial agent selected for initial treatment.

METHODS

We audited laboratory logs and medical records to retrospectively identify incident cases of culture-confirmed PSD in children at a large university-affiliated health system during 2006-2008. We estimated rates of recurrence (defined as any return visit with a clinical diagnosis of perineal dermatitis within 6 months) and, then, incorporated these rates into a meta-analysis that included 8 previous studies.

RESULTS

A total of 81 children had incident PSD during the study period, and 26 (32.1%) had a recurrence. Most (18/26 [69.2%]) had their first recurrence within 6 weeks. Among children treated with an oral agent, the recurrence rate was 16/42 (38.1%) following penicillin or amoxicillin and 10/36 (27.8%) following a beta-lactamase resistant agent (adjusted odds ratio: 2.02 [95% confidence interval {CI}: 0.69-5.92]). In the meta-analysis, recurrence rates following penicillin or amoxicillin were consistent across studies (fixed-effect test for heterogeneity, P = 0.35), and the pooled rate (37.4% [95% CI: 28.8%-46.5%]) was higher than observed following a beta-lactamase resistant agent (odds ratio: 2.39 [95% CI: 1.18-4.81]).

CONCLUSIONS

Perineal streptococcal dermatitis initially treated with penicillin or amoxicillin is consistently associated with a high risk of clinical recurrence. Whether treatment with a beta-lactamase resistant agent reduces this risk is uncertain and should be subjected to a clinical trial.

[Perianal streptococcal dermatitis caused by β-hemolytic group G streptococci in two adults]

Perianal streptococcal dermatitis is generally considered a childhood disorder caused by β-hemolytic group A streptococci. It should also be considered in cases of therapy-refractory gluteal erythema in adults. We report two cases of perianal streptococcal dermatitis in adults. In both, the microbiological examination of the skin swabs showed β-hemolytic group G streptococci. Therapy of choice is penicillin.

Streptococcus pyogenes pharyngeal colonization resulting in recurrent, prepubertal vulvovaginitis

BACKGROUND

Recurrent, prepubertal, vaginal infections are an uncommon, troublesome problem for the patient and her family. Failure of initial therapy to alleviate vulvovaginitis may be related to vulvar skin disease, foreign body, sexual abuse, pinworms, reactions to medications, anatomic anomalies, or allergies. This report describes a case of recurrent Streptococcus pyogenes vulvovaginitis secondary to presumed vaginal re-inoculation from pharyngeal colonization.

CASE

A 4-yr-old presented with one year of culture proven, recurrent Streptococcus pyogenes vulvovaginitis. Her symptoms repeatedly resolved with penicillin therapy, but continued to recur following cessation of antibiotic therapy. Evaluation included physical examination, trans-abdominal pelvic ultrasound, and vaginoscopy which all revealed normal upper and lower genital tract anatomy. Both the patient and her mother demonstrated culture proven, Group A Streptococcus pharyngeal colonization. Because of the possibility of repeated inoculations of the vaginal area from the colonized pharynx, they were both treated for decolonization with a regimen of amoxicillin and rifampin for ten days. Following this therapy there was resolution of vaginal symptoms with no further recurrence. Follow-up pharyngeal culture done on both mother and child on their last visit were negative for Group A Streptococcus.

CONCLUSION

This case demonstrated an unusual specific cause of recurrent vaginitis resulting from presumed self or maternal re-inoculation with group A beta-hemolytic streptococcus from pharyngeal colonization. Group A beta-hemolytic streptococcus are consistently sensitive to penicillin, but up to 25% of acute pharyngitis cases treated with penicillin having continued asymptomatic, bacterial carriage within the nasopharynx. Thus initial alleviation of symptoms in a patient with Group A beta-hemolytic vulvovaginitis treated with penicillin, can have continued asymptomatic pharyngeal colonization which can result in recurrence of the vulvovaginitis. This case stresses the importance of considering re-infection through this route in the patient with recurrent Group A beta-hemolytic streptococcus vulvovaginitis.

[Isolation of group A beta-hemolytic Streptococcus in children with perianal dermatitis]

INTRODUCTION

Perianal dermatitis due to group A beta-hemolytic streptococcus is a rare diagnosis in pediatrics. Clinical manifestations include erythema, edema, and perianal pruritus associated with vulvovaginitis or balanitis, painful defecation, constipation, anal fissures, purulent discharge, and/or rectal bleeding.

MATERIAL AND METHODS

A descriptive, observational, prospective study was conducted between May, 2004 and April, 2005. In children presenting to the emergency room with erythema, edema, and perianal pruritus, a rapid streptococcal antigen test and bacterial cultures of their perianal secretions were obtained. Patients with a positive result in the rapid test were treated with oral phenoxymethylpenicillin (40-50 mg/kg/day) for 10 days, after which clinical and bacteriological evaluations were conducted.

RESULTS

Of the 24 patients presenting with erythema, edema, and perianal pruritus, 19 patients (12 boys and 7 girls), aged between 6 months and 4 years (median age: 30 months), tested positive for group A beta-hemolytic streptococcus. Nine patients also presented with constipation, 5 with anal fissures, 4 with rectal bleeding, 2 with vulvovaginitis, and 1 with streptococcal pharyngoamygdalitis. Outcome was favorable in 85 % of the patients, and perianal isolation of group A beta-hemolytic streptococcus was negative after treatment in 95 %.

CONCLUSIONS

In patients presenting with erythema, edema, and perianal pruritus, perianal streptococcal dermatitis should be ruled out. The rapid test for streptococcal antigen detection is a quick and reliable method for this diagnosis. The antibiotic of choice is oral penicillin.

Perineal streptococcal dermatitis/disease: recognition and management

Perianal streptococcal dermatitis (PSD) is a pediatric dermatologic infectious disease predominantly affecting children, particularly younger children, which is most commonly caused by group A beta-hemolytic streptococci (GABHS). Although the clinical picture of a sharply demarcated erythema is very characteristic, PSD is often misdiagnosed for long periods of time and patients are subjected to treatments for a variety of differential diagnoses. Vulvar and penile involvement with similar signs and symptoms have been documented in several patients with PSD. The diagnosis is made by either a swab of the affected region submitted for microbiological analysis with the specific question for GABHS, or a rapid strep test. Systemic antibiotics such as penicillin, erythromycin, newer macrolides, or others, probably augmented by topical antiseptic or antibiotic ointments are the treatment of choice. Treatment duration should be at least 14 days or, even better, 21 days, and be dictated by clinical and microbiological cure. Therefore treatment success should be investigated not only by clinical examination but also by post-treatment perineal swabs as well as a urine analysis to monitor for post-streptococcal glomerulonephritis. The author of this review supports the recent suggestion to summarize GABHS-induced vulvovaginal and penile infections together with PSD under the inclusive term 'perineal streptococcal disease' because these conditions coincide, share important clinical characteristics and, therefore, represent manifestations of the same disease.

Streptococcal intertrigo: an underrecognized condition in children

Group A beta-hemolytic streptococci have been implicated in a variety of common childhood cutaneous infections. Infants and young children may be particularly susceptible to a form of streptococcal intertrigo that has heretofore been underrecognized in this population. Manifesting as intense, fiery-red erythema and maceration in the intertriginous folds of the neck, axillae, or inguinal spaces, the condition is characterized by a distinctive foul odor and an absence of satellite lesions. Specific clinical features help differentiate this condition from its clinical mimics. Topical and oral antibiotic therapy with or without concomitant low-potency topical steroid application is generally curative.

Community outbreak of perianal group A streptococcal infection in Denmark

BACKGROUND

Perianal group A streptococcal infection (PASI) occurs primarily in children. There is limited information on the incidence, transmission and treatment of PASI. We report a cluster of cases connected to a Danish kindergarten and observations of the incidence of PASI in the local population.

SETTING

A Danish rural community with 1765 children 15 years and younger registered with two general practice clinics.

METHODS

After being alerted of a possible cluster of PASI cases, all isolates of group A beta-hemolytic streptococci were collected and subjected to T typing and pulsed field gel electrophoresis (PFGE) if grown from either a rectal swab or an accompanying throat swab obtained in the offices of local general practitioners during the ensuing 4-month period. Clinical data were obtained from the files of the local general practitioners.

RESULTS

Twelve cases of PASI were caused by group A beta-hemolytic streptococci T type 28 with an identical PFGE profile: 6 of the cases were in children attending the same kindergarten, 4 were connected otherwise to the cluster and 2 cases seemed to be unrelated. Five cases of PASI with different T types and PFGE profiles were diagnosed during the same period giving an estimated annual incidence of 2 to 7 per 1000 children. Penicillin V was ineffective in 3 cases, and no recurrence was seen after change of the treatment to oral clarithromycin.

CONCLUSIONS

A clone of T type 28 seemed to be the cause of the largest cluster of PASI cases described thus far. Clarithromycin was effective as second line treatment. An estimated annual baseline incidence of 2 to 7 per 1000 in the local population indicates that PASI may not be as rare as previously estimated.

Perineal group A streptococcal disease in a pediatric practice

OBJECTIVE

This study was designed to document the frequency and define the clinical, epidemiologic, and microbiologic characteristics of perineal disease caused by group A beta-hemolytic streptococci (GAS) in a pediatric practice in which increased numbers of cases had been observed.

METHODS

Clinical, epidemiologic, and microbiologic data were collected on all culture-confirmed cases of perineal GAS disease during the calendar year 1997. GAS isolates from clinical cases and a comparison group of children with GAS pharyngitis were analyzed by T typing, emm gene analysis, and pulsed-field gel electrophoresis (PFGE).

RESULTS

Twenty-three cases of GAS perineal disease were diagnosed during 4530 office visits in 1997. Thirteen cases had perianal disease, 8 had vulvovaginal infection, and 2 were infected at both sites. No cases of penile disease were identified. Infections peaked in late winter and early spring and affected children with an average age of 5 years with a range of perineal, gastrointestinal, and genitourinary symptoms. Analysis of T and emm types showed the majority (82%) of perineal isolates to be T 28 emm 28, showing 2 closely related PFGE patterns. In contrast, the pharyngeal isolates were distributed among 6 different T and emm types.

CONCLUSION

Perineal infection caused by GAS may be a relatively common diagnosis in a pediatric or family practice setting. There may be specific GAS types that have a tropism for perineal tissues but the mechanism of infection is yet to be established.

Microbiology of perianal cellulitis in children: comparison of skin swabs and needle aspiration

OBJECTIVE

To establish the aerobic and anaerobic microbiology of perianal cellulitis in children, comparing skin swab and needle aspirate methodology.

METHOD

Swabs of involved skin and needle aspirates of cellulitis were studied for aerobic and anaerobic bacteria.

RESULTS

Specimens obtained from 10 patients with perianal cellulitis showed bacterial growth. Polymicrobial aerobic-anaerobic flora was found in all skin surface cultures, where the predominate isolates were Peptostreptococcus spp., Escherichia coli, and alpha hemolytic streptococci. The number of isolates in needle aspirates varied between one and two. The predominant ones were E. coli (3), Peptostreptococcus spp. (3), Staphylococcus aureus (2), and Bacteroides fragilis group (2). Complete or partial concordance in microbiology between skin swabs and needle aspirates was present in six instances. In four instances, isolates recovered from needle aspirates were not isolated from the skin surface.

CONCLUSIONS

This study demonstrates the diversity of aerobic and anaerobic organisms isolated from perianal cellulitis, and the superiority of needle aspirates in establishing the microbiology of the infection.

An epidemiologic study of perianal dermatitis among children in Egypt

Perianal dermatitis is a common problem occurring among infants and children. Streptococci, particularly beta-hemolytic group A organisms, play a major role in its causation. An epidemiologic association between perianal dermatitis caused by group A beta-hemolytic streptococci in some patients and pharyngeal colonization with the same organisms seems to exist. A similar relation is also true for other organisms, including non-group A beta-hemolytic streptococci and Staphylococcus aureus. This was the main conclusion of a hospital-based study performed on 150 children with perianal dermatitis. All patients were subjected to a questionnaire, clinical examination, two perianal swabs, and two throat swabs. The bacteriologic examination of the perianal swabs revealed the presence of beta-hemolytic streptococci in 35.3% of the cases, half of which were of the group A beta-hemolytic strain (17.3%) and half of which were non-group A (18%). Throat swabs revealed the presence of beta-hemolytic streptococci in 44% of cases, half of which were found to belong to group A (21.3%) and half to non-group A (22.7%). Among patients with perianal dermatitis caused by group A beta-hemolytic streptococci, 53.8% had associated pharyngeal colonization by the same organism. S. aureus was isolated from the perianal skin in five patients (3.4%); in four of whom the same organism also grew in cultures from throat swabs. A relatively good association between pharyngeal colonization by beta-hemolytic streptococci and Staphylococci and the presence of perianal dermatitis caused by the same organisms was demonstrated using the Kappa test of agreement (K = 0.4).

Perianal streptococcal dermatitis in adults

Perianal streptococcal dermatitis is an uncommon superficial cutaneous infection of the perianal area almost exclusively described in children. We report here four adult cases. Beta-haemolytic streptococcus group A was detected in the perianal areas of all the patients. Systemic erythromycin gave complete resolution. The incidence of perianal streptococcal dermatitis in adults is probably underestimated, and culture from the affected area should always be performed in patients with persistent perianal erythema.

Perianal streptococcal dermatitis associated with guttate psoriasis and/or balanoposthitis: a study of five cases

Perianal streptococcal dermatitis (PSD) is a recently described cutaneous entity caused by group A beta-hemolytic streptococci. It is characterized by perianal erythema, sometimes associated with functional disturbances. We describe four children (2 boys, 2 girls) who had acute guttate psoriasis and also PSD. One of these patients also had balanoposthitis. A fifth patient experienced an association of PSD and balanoposthitis without psoriasis. To our knowledge, the association between guttate psoriasis and PSD has only been reported in five children, and the one with balanitis has not been previously reported.

Perianal infection with beta haemolytic streptococcus

A prospective study of 50 children with beta haemolytic streptococcal perianal infection and related disorders identified oedematous perianal skin and cracking on parting the buttocks, forming superficial multiple fissuring, as the characteristic features of such infection, and confirmed the value of skin culture in its diagnosis. Treatment by oral amoxycillin with clavulanic acid and a topical ointment containing bacitracin was effective in all patients.

Staphylococcus aureus as a cause of perianal dermatitis

Perianal dermatitis has been reported to be caused by group A beta-hemolytic Streptococcus. We present a case caused by Staphylococcus aureus. A clinical clue pointing to this organism was the presence of satellite pustules. Identifying the pathogen in perianal dermatitis is therapeutically important, as oral penicillin VK will not be effective if S. aureus is the true cause. Other streptococcal and staphylococcal cutaneous infections may exhibit overlapping clinical features, including scarlet fever, impetigo, toxic shock syndrome, and cellulitis.

Perianal group A streptococcal infection

Four cases of perianal group A streptococcal infection presented with typical features of this condition; but because of lack of recognition appropriate therapy was delayed. Once group A streptococcal infection was diagnosed there was a high frequency of relapses. The need for prolonged treatment is illustrated.

Faecal incontinence due to perianal cellulitis

A 4-year-old boy presented with a 6-week history of painful defaecation and faecal incontinence due to streptococcal perianal cellulitis. After treatment with a 10-day course of oral penicillin his symptoms had fully resolved. Early diagnosis and treatment of this under-recognised condition is essential.

Perianal streptococcal cellulitis with penile involvement

Perianal streptococcal cellulitis is described occurring in a 5-year-old boy. The condition also involved the penis and presented as a possible case of sexual abuse. The correct diagnosis was established by culturing beta-haemolytic streptococci group A from the penile and perianal skin.

Perianal streptococcal dermatitis

Eight patients were treated for perianal streptococcal dermatitis. The condition previously was described as perianal cellulitis, a term that is confusing in light of the clinical features and distinctive appearance of the disorder.