2019 Research Forum

Christina Sugirtharaj MPH MS IV, Simmer Kaur MD R2, Andrew Sahakian MS IV, Mandakini Patel MD R3, Arash Heidari MD, Greti Petersen MD Group A Streptococcus Puerperal Sepsis After Spontaneous Abortion

CASE PRESENTAITON

CONCLUSION Group A Streptococcal puerperal sepsis is a life-threatening infection that can lead to maternal mortality. GAS puerperal sepsis is a preventable condition. In this case of GAS bacteremia, the patient had a spontaneous abortion and electively used a sex toy while still passing products of conceptions. As a result, it could be highly possible that the patient introduced the bacteria into her vaginal canal eventually leading to bacteremia. In this patient, it is unsure whether the pelvic cul-de-sac abscess was due to the current infection or from a prior infection. However, as maternal morbidity is high in GAS bacteremia, it was imperative that this patient’s infection was controlled and the abscess drained. 1. Binghuai, L., Wenjun, S., & Xinxin, L. (2013). Intrauterine infection and post-partum bacteraemia due to Streptococcus gallolyticus subsp. pasteurianus.Journal of Medical Microbiology,62(Pt_10), 1617-1619. doi:10.1099/jmm.0.054106-0 2. Golden, S. (2003). Group A streptococcus and streptococcal toxic shock syndrome: A postpartum case report. Journal of Midwifery & Womens Health,48(5), 357- 359.doi:10.1016/s1526-9523(03)00284-8 3. Palaniappan, N., Menezes, M., & Willson, P. (2012). Group A streptococcal puerperal sepsis: Management and prevention. The Obstetrician & Gynaecologist,14(1), 9-16. doi:10.1111/j.1744-4667.2011.00082.x 4. Zakour, N. L., Venturini, C., Beatson, S. A., & Walker, M. J. (2012). Analysis of a Streptococcus pyogenes Puerperal Sepsis Cluster by Use of Whole-Genome Sequencing. Journal of Clinical Microbiology,50(7), 2224-2228. doi:10.1128/jcm.00675-12 5. Chuang I, Van Beneden C, Beall B, Schuchat A. Population ‐ based surveillance for portpartum invasive group A streptococcus infections, 1995–2000. Clin Infect Dis 2002;35:665–70 [ http://dx.doi.org/10.1086/342062 ]. 6. Hebert PR, Reed G, Entman S, Mitchel E, Berg C, Griffin M. Serious maternal morbidity after childbirth: prolonged hospital stays and readmissions, Obstet Gynecol , 1999, vol. 94 (pg. 942-7) REFERENCES

OBJECTIVES

This case presentation is about a 44 year old G18P2T7A9L9 African American female patient with a history of hypertension and multiple spontaneous abortions who presented to the Emergency Department complaining about diarrhea and abdominal pain. Three days prior she had a spontaneous abortion. She was febrile at 102.4, tachycardic at 102 beats per minute, and tachypneic at 24 breaths per minute. A diagnosis of sepsis was made and the patient was started on Vancomycin and Meropenam. A CT scan indicated retrouterine abscess measuring about 5.7 x 4.2 x 5.4 cm. Blood cultures were positive for Group A Streptococcus (Figure 1). Antibiotics were changed to Levofloxacin 750mg daily due to susceptibility. Further testing to determine etiology of spontaneous abortions were negative. On further inquiry, the patient revealed the use of a intravaginal sex toy the day after her spontaneous abortion while she was passing products of conception. It was then agreed that patient was bacteremic with Group A streptococcus secondary to endometritis with pelvic abscess and enterocolitis. With the help off interventional radiology, the pelvic abscess was drained with gram stain and culture indicating no organisms. Pathology noted only polymorphonuclear leukocytes with no organisms or malignancy noted as seen in figure 2. Patient was discharged on a 21 day course of Levofloxacin. A repeat CT a week later indicated a decrease in size of the abscess from 5.7 cm to 2.8 cm. At a follow up clinic visit, the patient had resolution of her all symptoms.

 To understand the management of Group A Streptococcal (GAS) puerperal sepsis  To understand the complications associated with GAS puerperal sepsis  To understand the risk factors associated with GAS transmission in a post partum setting Group A streptococcal (GAS) puerperal sepsis is a serious and life threatening condition that affects 3 to 4 cases per 100,000 population worldwide [3]. It was considered the leading cause of maternal death in the developing world. The most common mode of transmission was person to person which markedly decreased with the implementation of hand washing in the 1840s. In the United States, an estimated 6% of women in their postpartum have the infection which can lead to sepsis [5] . A study published in Clinical Infectious Disease indicated that in puerperal GAS infections 64% were seen in Caucasians patients with 28% in African Americans. It was noted that the rate of the GAS was 1.6 to 2.0 fold greater among the African American population. With proper diagnosis and management these incidences can further decrease maternal post partum related deaths.

BACKGROUND

Figure 1 – Group A Strep from patient’s blood Photo courtesy of Microbiology Department at Kern Medical Center

Figure 2 – Aspirate of abscess; Pathology slide of pelvic abscess sample indicating only PMNs Photo courtesy of Pathology Department and Interventional Radiology Department at Kern Medical Center

ACKNOWLEDGEMENTS

Thank you to the staff at Kern Medical Center whose timeless efforts made this learning opportunity possible. Also a special thank you to the Interventional Radiology department and to the Laboratory department .

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