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CASE REPORT
Year : 2004  |  Volume : 22  |  Issue : 4  |  Page : 263-265
 

Extensive deep neck space abscess due to B-Haemolytic group G Streptococci-A case report


Department of Microbiology, Sri Devaraj Urs Medical College, Tamaka, Kolar - 563 101, Karnataka, India

Date of Submission28-Jan-2004
Date of Acceptance02-May-2004

Correspondence Address:
Department of Microbiology, Sri Devaraj Urs Medical College, Tamaka, Kolar - 563 101, Karnataka, India

 ~ Abstract 

Beta haemolytic phenotype of group G streptococci was isolated from the pus obtained from a patient with extensive deep neck space abscess. Patient was immunocompetent and made complete recovery after surgical drainage and administration of amoxycillin with clavulanic acid, amikacin and metronidazole. To our knowledge, this is the first report of deep neck space abscess due to group G streptococci.

How to cite this article:
Malini A, Mohiyuddin S M, Brahmadathan K N, Prasad S R. Extensive deep neck space abscess due to B-Haemolytic group G Streptococci-A case report. Indian J Med Microbiol 2004;22:263-5


How to cite this URL:
Malini A, Mohiyuddin S M, Brahmadathan K N, Prasad S R. Extensive deep neck space abscess due to B-Haemolytic group G Streptococci-A case report. Indian J Med Microbiol [serial online] 2004 [cited 2019 Sep 18];22:263-5. Available from: http://www.ijmm.org/text.asp?2004/22/4/263/12822


Deep neck space abscess is a rapidly progressive condition often seen in immunocompromised individuals and those with poor oral hygiene. It rapidly extends to various deep neck spaces and often can be life threatening, as it can lead to upper airway obstruction or septicaemia.[1] Deep neck space abscesses are commonly caused by organisms of odontogenic origin such as alpha haemolytic streptococci, Staphylococcus aureus, Staphylococcus epidermidis, Haemophilus influenzae,  Neisseria More Details spp., Klebsiella spp., Pseudomonas spp. and diphtheroids.[1]
We report here, a case of extensive deep neck space abscess due to group G streptococci. Group G streptococcal infections are thought to be on rise in the recent years.[2] Severe infections such as necrotizing fasciitis due to group G streptococci (GGS) have been reported.[3],[4],[5] Reports on GGS infection from India are very few[6] and to our knowledge this is the first report of GGS causing deep neck space abscess.

 ~ Case Report Top

A 50 year old patient from Nakkanapalli village in Chittor district, Andhra Pradesh, was admitted to the ENT ward of RLJ Hospital, Kolar with complaints of fever and swelling over left side of the neck, which was associated with pain during swallowing.
On examination he was found to be febrile and had a tender, fluctuant swelling of 4x5cm size over the left submandibular region. Haemogram showed a total WBC count of 24,000 cells/cmm with neutrophils 82%, lymphocytes 14% and eosinophils 4%. His hemoglobin was 11.5gm% and random blood sugar was 110mg%. Serological studies for HBsAg (Hepacard) and HIV antibodies (Tridot) were negative.
Within a period of two days, the swelling progressed to involve the submental, parapharyngeal, retropharyngeal and paratracheal regions. It extended from the mandible to an inch above the clavicle. There was a small island of blackish discolouration on skin. The trachea was shifted to the right side. The patient also developed trismus and stridor. A diagnosis of extensive deep neck space abscess with airway obstruction was made. Emergency tracheostomy with incision and drainage of the abscess was performed. During surgery, the abscess was found to be involving the submental triangle, submandibular fossa, parapharyngeal and retropharyngeal spaces. It extended till the prevertebral ligaments and paratracheal region. These regions were full of pus, liquefied material and slough. The muscles and fascia were found to be extensively necrosed as evidenced by avascular, friable tissue with absence of vitality.
The pus sample was received for culture and sensitivity. Gram stain of the pus sample showed numerous polymorphonuclear and mononuclear cells. No bacteria could be seen. The Zeihl-Neelsen stain was negative for acid fast bacilli. Culture yielded small beta-haemolytic colonies on blood agar after 72 hours of incubation at 37C [Figure - 1]. Two colony morphological forms could be discerned, a larger colony with wide zone of haemolysis and smaller colony with narrower zone of haemolysis. Smears from the colonies on Gram stain showed gram positive cocci arranged in pairs and small chains. The strain also grew on Mueller-Hinton agar producing small transparent colonies. It was catalase negative and bacitracin sensitive.
Both the colonial types were identified as GGS by micronitrous acid extraction procedure using the coagglutination reagents, developed at CMC, Vellore. The grouping was also confirmed by Lancefield extraction, capillary precipitation technique and by the latex agglutination kit of Murex Biotech Ltd., UK. Sensitivity test was done on blood agar using Kirby Bauer disc diffusion method. The strain was sensitive to penicillin, erythromycin, chloramphenicol, tetracycline, cefazolin, cefuroxime, ceftriaxone and netilmycin. The patient was treated with amoxycillin with clavulanic acid, metronidazole and amikacin during the postoperative period even before the antibiogram became available. Regular antiseptic irrigation of the abscess cavity was performed with povidone-iodine and hydrogen peroxide.
On third postoperative day, patient developed duodenal perforation due to stress ulcer which was promptly closed after laparotomy. The neck wound healed well and the patient was discharged on 17th post operative day after complete recovery.

 ~ Discussion Top

GGS form a part of the normal flora of oropharynx, gastrointestinal tract and skin.[3] They have been incriminated in the infections of skin and soft tissues, bones and joints, respiratory tract and genital tract. They are also known to cause septicaemia.[3],[6] Here we report extensive deep neck space abscess due to GGS, which was the sole isolate from the pus obtained from the lesion. Extensive literature search conducted by us did not reveal any report of deep neck abscess due to group G streptococci.
Most of the GGS infections are seen in patients with underlying debilitating conditions such as diabetes mellitus, cirrhosis, malignancy and alcoholism.[3],[7] Our patient was immunocompetent and did not have any of these debilitating conditions.
Life threatening necrotizing soft tissue infections, such as the one described here are thought to occur due to complex interplay between virulence of the strain and the host response.[4] GGS share virulence factors such as M protein, streptokinase, fibronectin, IgG binding proteins, streptolysin O, streptolysin S, C5a peptidase, NADase and possibly the hyaluronic acid capsule with Group A streptococci.[5] Beta haemolysis of GGS has been attributed to streptolysin S, which is coded by the genes of SAG operon. It has been shown to play key role in the pathogenesis of necrotizing GGS infections.[5] The GGS isolated by us showed a wide zone of beta haemolysis. Penicillin is the drug of choice for treating streptococcal infections of skin and soft tissues.[4] In treating severe GGS infections, however, combination of a penicillin with aminoglycosides has been recommended.[8],[9] Our patient was started on a similar combination along with metronidazole, to which he responded promptly.
Our report brings in to focus, the importance of GGS as a pathogen. Virulent phenotypes of GGS produce beta haemolysis like Group A streptococci; 3-5% of GGS moreover, can also be sensitive to bacitracin. We would have missed the identity of the pathogen if we had not done grouping. Hence we stress the need for routine grouping of all beta-haemolytic streptococci. 

 ~ References Top

1.Scott BA, Stiernberg CM, Driscoll BP. Deep neck space infections. In: Head and neck surgery - Otolaryngology, 2nd ed, Vol.1. Bailey BJ, Calhoun KH, Deskin RW, Johnson JT, Kohut RI, Pillsbury III HC, Tardy Jr ME. Eds. (Lippincott-Raven publishers, Philadelphia).1998:819-835.  Back to cited text no. 1    
2.Vartian C, Lerner PI, Shlaes DM, Gopalakrishna KV. Infections due to Lancefield Group G streptococci. Medicine 1985;64:75-88.  Back to cited text no. 2  [PUBMED]  
3.Sylvetsky N, Raveh D, Schlesinger Y, Rudensky B, Yinnon MA. Bacteremia due to ?-hemolytic streptococcus group G: Increasing incidence and clinical characteristics of patients. Am J Med 2002;112:622-626.  Back to cited text no. 3    
4.Alan BL, Dennis SL. Streptococcal infections of skin and soft tissues. New Eng J Med 1996;334:240-245.  Back to cited text no. 4    
5.Humar D, Datta V, Bast JD, Beall B, Azavedo J, Nizet V. Streptolysin S and necrotizing infections produced by Group G streptococcus. Lancet 2002;359:124-129.  Back to cited text no. 5    
6.Brahmadathan KN, Koshi G. Importance of Group G streptococci in human pyogenic infections. J Trop Med Hyg 1989;92:35-38.  Back to cited text no. 6    
7.Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001;110:1051-1054.  Back to cited text no. 7    
8.Gallis HA. Streptococcus. In: Zinsser Microbiology, 19th ed. Joklik WK, Willett HP, Amos BD, Wilfert CM. Eds. (Prentice-Hall International Inc, USA).1988:365.  Back to cited text no. 8    
9.Jankowski S, MacLachlan K, Stephenson J, Thomas P. Necrotising infections and group G streptococcus. Lancet 2002;359:2277.  Back to cited text no. 9    
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2004 - Indian Journal of Medical Microbiology
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