Impetigo neonatorum associated with late onset group B
streptococcal meningitis
Ananya Guha, Michael Eisenhut, , Paul Shears and Mark Dalzell
Royal Liverpool Childrens NHS Trust, Alder Hey, Eaton Road, Liverpool L12 2AP,
UK
Accepted 13 April 2003. ; Available online 29 May 2003.
Abstract
We present a case of nonbullous impetigo neonatorum associated with
late onset group B streptococcal meningitis in a 12-day-old infant. Both
skin lesions and meningitis resolved with antibiotic therapy. This is the
first reported case of meningitis during the course of this skin disease.
Author Keywords: Impetigo; Group B streptococcus;
Meningitis; Neonate
Impetigo neonatorum is a form of impetigo occurring in neonates from
birth to the second week of life. Skin areas predominantly affected are
moist areas under the diaper, around the neck, groins and axillae.[1] Organisms isolated from the lesions included
Staphylococcus (S.) aureus and Group B streptococcus (GBS).[2, 3, 4 and
5] Impetigo in neonates has not been associated with
systemic manifestations. Skin lesions reported in late onset GBS
meningitis are erysipelas and cellulitis. [6 and
7] We report the first case of GBS meningitis
associated with impetigo neonatorum.
2. Case report
This male infant was born at term by normal vaginal delivery with a
birth weight of 3.2 kg. There was no history of prolonged rupture of
membranes, no maternal pyrexia or evidence of maternal GBS carriage, or
impetigo in close contacts. He was breast-fed from birth and had mild
physiological jaundice on the second day. Mother had cracked nipples on
the fourth day but she continued with breast-feeding.
Two days prior to admission mother noted pin prick like, red spots over
the lower abdomen in the area covered by the diaper. A few more similar
lesions appeared the day before admission. A yellow crust on an enlarged
erythematous base developed and the infant became unwell with poor feeding
and an abnormal cry.
On admission, on the twelfth day of life, the infant was pyrexial (38.5
°C) and irritable. There were no symptoms or signs of cardiovascular or
respiratory compromise. The anterior fontanelle was full. Three skin
lesions compatible with impetigo were noted over the infraumbilical region
(see Fig. 1). An infection screen was performed and
intravenous cefotaxime commenced. Cerebrospinal fluid (CSF) revealed
gram-positive bacteria on staining, which were identified as GBS. CSF
glucose was <0.5 mmol/l, protein 3.8 g/l (normal range 0.31.2 g/l), and
the cell count showed 723 white blood cells per microliter. Blood cultures
also isolated GBS. A urine culture was sterile and a chest X-ray was
normal. From skin swabs of the impetigo lesions S. aureus was
isolated. Culture of maternal breast milk also revealed a growth of this
organism.
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Figure 1. Impetigo neonatorum in a case of group B streptococcal
meningitis.
The infant made an uneventful recovery. The skin lesions healed within
five days after admission without scar or abnormal pigmentation. A 2-week
course of intravenous cefotaxime was completed.
3. Discussion
Although GBS was not cultured from skin lesions we think the skin
lesions and the GBS meningitis were not a mere coincidence. In nonbullous
impetigo S. aureus has previously been detected together with GBS
in the same lesions.[8] Mitis Salivarius agar plates
conducive to growth of GBS, were not used for culture in this instance.
This may have prevented detection of streptococci in the mixture with
S. aureus. S. aureus is known to produce an anti-streptococcal
bacteriocin inhibiting concomitant growth of GBS.[9]
Breastmilk has previously been described as an important source of
infection in late onset group B streptococcal meningitis.[10] We could not exclude maternal breast milk as a
source of the infection because S. aureus cultured from the milk
may have obscured the presence of GBS.
This case illustrates that the skin may be an entry site for GBS
causing late-onset meningitis. Early systemic antibiotic therapy covering
both S. aureus and GBS in impetigo neonatorum is necessary to
prevent this potentially fatal complication.
References
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9. A. Iqbal, S.A. Ali, A. Abbasi, W. Volter and
S.A. Rasool, Production, purification and some properties of Bac201, a
bacteriocin-like inhibitory substance produced by Staphylococcus aureus
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Pediatr Infect Dis J21 (2002), pp. 567568.
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