Case Report | Open Access
First Described Case of Group B Streptococcus Pelvic Abscess in a Patient with No Medical Comorbidities
Background. Group B Streptococcus is an organism that commonly infects a wide range of hosts including infants in the first week of life, pregnant women, and older age adults as well as adults with underlying medical comorbidities. Case. Large pelvic abscess in a nonpregnant patient found to be caused by Group B Streptococcus was treated successfully with IR guided drainage and antibiotics. Conclusion. Though rare, GBS can still be a cause of invasive infection even in individuals who are nonpregnant and have no underlying comorbidities. Empiric antibiotic coverage for this organism should be kept in mind when treating an abscess.
Invasive Group B Streptococcus (GBS), a leading cause of illness and death among infants in the first week of life and of infection in pregnant women, also causes significant morbidity and mortality among nonpregnant adults . GBS has been traditionally considered a neonatal pathogen; however due to effective screening and intrapartum chemoprophylaxis the incidence of the disease has drastically fallen among this population [1, 2].
Recently GBS has emerged as an important cause of invasive infection in nonpregnant adults. In a large, population-based analysis the incidence of adult GBS disease has more than doubled over an observed 18-year study period from 3.6 cases per 100,000 persons in 1990 to 7.3 cases per 100,000 in 2007 . Typical presentations of GBS disease in adults include bacteremia without focus and skin and soft-tissue infection. Other serious clinical syndromes, such as meningitis, pneumonia, streptococcal toxic shock syndrome, and endocarditis, are rare but are often associated with considerable morbidity and mortality [1, 4–11]. Nonfocal bacteremia and pneumonia were more common among patients aged 65 years and older. Osteomyelitis, skin and/or soft-tissue infection, peritonitis, meningitis, and necrotizing fasciitis were more common among younger adults . Among adults, the most common risk factors for invasive GBS disease are older age and medical comorbidities; 88% of cases occur among persons with one or more underlying chronic medical conditions, especially diabetes [3–6, 8–10]. We highlight a rare case of GBS pelvic abscess in a nonpregnant patient with no significant comorbidities.
A 43-year-old G2P1011 with a history of total vaginal hysterectomy six years before presentation, laparoscopic ovarian cystectomy, and a remote history of pelvic inflammatory disease presented to our emergency department with four days of pelvic pain, low-grade fever, chills, anorexia, and body aches.
On admission, the patient was febrile to 38.4°C and found to have leukocytosis (white count 14,900/mm3) with a left shift. While the patient was in the ED a pelvic ultrasound was obtained and was significant for a large (7.0 × 5.2 × 6.9 cm) heterogeneous complex lesion with multiple septations in the left adnexa with apparent fallopian tube involvement concerning for tuboovarian abscess. The decision was made to admit the patient. A pelvic CT with contrast was completed (Figure 1) and found a multiloculated cystic mass measuring 7.9 cm with enhancing walls in the pelvis diagnostic of a pelvic abscess. No noted abnormalities were seen in the small bowel or colon.
After blood cultures had been drawn in the ED, which yielded no growth at five days, the patient was empirically started on IV Cefoxitin, Doxycycline, and Flagyl and referred to our interventional radiology department for possible drainage. On day 1 of admission, an 8.5-French Cook all-purpose drainage catheter was placed transgluteally within the pelvic abscess (Figure 2). After placement, the Cook catheter drained purulent material that was subsequently sent for culture. The specimen showed Gram-positive cocci that speciated to GBS, resistant to clindamycin and erythromycin.
Over the course of the admission the patient clinically improved, she remained afebrile, leukocytosis resolved to normal, and drainage decreased gradually. Four days after the catheter placement an interval CT showed a marked improvement of the pelvic abscess with only small residual locules of fluid found adjacent to the drainage catheter. At this stage, the interventional radiology team removed the catheter with no noted complications (Figure 3).
The patient remained afebrile with resolved leukocytosis and was discharged home on a course of oral antibiotics with follow-up in two weeks.
Upon thorough review of the literature, all large studies describing GBS disease burden among multiple populations fail to mention GBS as a causative microorganism of deep-seeded pelvic abscesses. A search of the English literature using PubMed was conducted; cases were included if the patient was a nonpregnant adult with an abscess occurring in the pelvis or abdominal cavity. To the best of our knowledge, this is the first case of a sporadic pelvic abscess of unknown origin in a previously healthy patient with no medical comorbidities.
Published cases of deep-seeded GBS abdominal or pelvic abscesses were reported in patients with previous comorbidities, mostly diabetes, and involved an infection of the kidney [12–14], bladder , prostate , adrenal gland , liver , and uterus . One case of sporadic GBS abdominal abscess was recently described in 2015 .
The most common cause of pelvic abscesses is fistula formation. The majority of cutaneous fistulas represent a complication of recent abdominal surgery . The leading causes of internal fistulas are Crohn’s disease, diverticulitis, malignancy, or a complication of treatment of these entities [22–26]. Other causes of pelvic abscesses include tuboovarian abscess (TOA) and complication following surgery for a ruptured appendix.
The predominant bacteria in intra-abdominal and pelvic abscesses with an intestinal culprit are polymicrobial in origin and the most common isolates in most series are the B. fragilis group and E. coli [27, 28]. Pelvic abscesses caused by TOAs are predominantly also polymicrobial in nature, although Neisseria gonorrhoeae and Chlamydia trachomatis are occasionally cultured in sexually active women of the reproductive age [29–31].
Overall, this case we present is unusual for numerous reasons. The monobacterial nature of the pelvic abscess, the deep-seeded pelvic site, the absence of an ascending route given the history of total vaginal hysterectomy with an intact vaginal cuff, and the lack of medical comorbidities in this patient make this finding extremely unlikely.
As the number of GBS infections is increasing yearly, clinicians are becoming more prone to include GBS as a culprit in their differential diagnoses for patients with multiple comorbidities, especially diabetes. This case, however, shows the ability of GBS to cause severe and invasive disease in a previously immunocompetent patient with no risk factors. Given the wide range of clinical presentations and capacity to cause invasive disease in healthy patients, clinicians should consider GBS in their differential, especially in sporadic abdominal or pelvic abscesses.
The authors declare that they have no competing interests.
- S. J. Schrag, S. Zywicki, M. M. Farley et al., “Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis,” New England Journal of Medicine, vol. 342, no. 1, pp. 15–20, 2000.
- C. R. Phares, R. Lynfield, M. M. Farley et al., “Epidemiology of invasive group B streptococcal disease in the United States, 1999–2005,” JAMA, vol. 299, no. 17, pp. 2056–2065, 2008.
- T. H. Skoff, M. M. Farley, S. Petit et al., “Increasing burden of invasive group B streptococcal disease in nonpregnant adults, 1990–2007,” Clinical Infectious Diseases, vol. 49, no. 1, pp. 85–92, 2009.
- L. A. Jackson, R. Hilsdon, M. M. Farley et al., “Risk factors for group B streptococcal disease in adults,” Annals of Internal Medicine, vol. 123, no. 6, pp. 415–420, 1995.
- D. Blancas, M. Santin, M. Olmo, F. Alcaide, J. Carratala, and F. Gudiol, “Group B streptococcal disease in nonpregnant adults: incidence, clinical characteristics, and outcome,” European Journal of Clinical Microbiology and Infectious Diseases, vol. 23, no. 3, pp. 168–173, 2004.
- M. M. Farley, R. C. Harvey, T. Stull et al., “A population-based assessment of invasive disease due to group B streptococcus in nonpregnant adults,” New England Journal of Medicine, vol. 328, no. 25, pp. 1807–1811, 1993.
- G. J. Tyrrell, L. D. Senzilet, J. S. Spika et al., “Invasive disease due to group B streptococcal infection in adults: results from a Canadian, population-based, active laboratory surveillance study—1996,” Journal of Infectious Diseases, vol. 182, no. 1, pp. 168–173, 2000.
- P. Y. Huang, M. H. Lee, C. C. Yang, and H. S. Leu, “Group B streptococcal bac-teremia in non-pregnant adults,” Journal of Microbiology, Immunology and Infection, vol. 39, pp. 237–241, 2006.
- B. Schwartz, A. Schuchat, M. J. Oxtoby, S. L. Cochi, A. Hightower, and C. V. Broome, “Invasive group B streptococcal disease in adults: a population-based study in metropolitan Atlanta,” The Journal of the American Medical Association, vol. 266, no. 8, pp. 1112–1114, 1991.
- M. M. Farley, “Group B streptococcal disease in nonpregnant adults,” Clinical Infectious Diseases, vol. 33, no. 4, pp. 556–561, 2001.
- P. Larppanichpoonphol and C. Watanakunakorn, “Group B streptococcal bacteremia in nonpregnant adults at a community teaching hospital,” Southern Medical Journal, vol. 94, no. 12, pp. 1206–1211, 2001.
- D. J. Baumgardner, “Perinephric abscess caused by group B streptococcus,” American Family Physician, vol. 69, no. 12, pp. 2764–2766, 2004.
- G. Santoro-Lopes, M. Halpern, and R. T. Gonçalves, “Perinephric abscess caused by Streptococcus agalactiae after renal transplantation,” Journal of Infection, vol. 51, no. 3, pp. e145–e147, 2005.
- H. A. Lopardo, P. Vidal, P. Jeric et al., “Six-month multicenter study on invasive infections due to group B streptococci in Argentina,” Journal of Clinical Microbiology, vol. 41, no. 10, pp. 4688–4694, 2003.
- K. B. Ulett, J. H. Shuemaker, W. H. Benjamin, C. K. Tan, and G. C. Ulett, “Group B streptococcus cystitis presenting in a diabetic patient with a massive abdominopelvic abscess: a case report,” Journal of Medical Case Reports, vol. 6, article 237, 2012.
- M. Procopiou, D. Genne, P. Abbet, N. Defabiani, S. Rohner, and R. Auckenthaler, “Acute prostatitis with prostatic abscess caused by group B Streptococcus,” Clinical Infectious Diseases, vol. 27, no. 2, pp. 403–404, 1998.
- R. Inoue, S.-I. Hisasue, Y. Kunishima, N. Masumori, N. Itoh, and T. Tsukamoto, “Pheochromocytoma with abscess,” International Journal of Urology, vol. 14, no. 7, pp. 644–646, 2007.
- J. M. Colford Jr., J. Mohle-Boetani, and K. L. Vosti, “Group B Streptococcal bacteremia in adults five years' experience and a review of the literature,” Medicine, vol. 74, no. 4, pp. 176–190, 1995.
- P. R. Genta, M. L. N. Dias, T. A. Janiszewski, J. P. Carvalho, M. H. Arai, and L. P. Meireles, “Streptococcus agalactiae endocarditis and giant pyomyoma simulating ovarian cancer,” Southern Medical Journal, vol. 94, no. 5, pp. 508–511, 2001.
- N. F. Crum-Cianflone, “An unusual case of a large, sporadic intra-abdominal abscess due to group B Streptococcus and a review of the literature,” Infection, vol. 43, no. 2, pp. 223–227, 2015.
- H. A. Thomas, “Radiologic investigation and treatment of gastrointestinal fistulas,” Surgical Clinics of North America, vol. 76, no. 5, pp. 1081–1094, 1996.
- P. J. Pickhardt, S. Bhalla, and D. M. Balfe, “Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation,” Radiology, vol. 224, no. 1, pp. 9–23, 2002.
- C. P. Delaney and V. W. Fazio, “Crohn's disease of the small bowel,” Surgical Clinics of North America, vol. 81, no. 1, pp. 137–158, 2001.
- R. J. Woods, I. C. Lavery, V. W. Fazio, D. G. Jagelman, and F. L. Weakley, “Internal fistulas in diverticular disease,” Diseases of the Colon & Rectum, vol. 31, no. 8, pp. 591–596, 1988.
- D. A. August, D. Serrano, and E. Poplin, “‘Spontaneous,’ delayed colon and rectal anastomotic complications associated with bevacizumab therapy,” Journal of Surgical Oncology, vol. 97, no. 2, pp. 180–185, 2008.
- S. E. Rubesin, I. Scotiniotis, B. A. Birnbaum, and G. G. Ginsberg, “Radiologic and endoscopic diagnosis of crohn's disease,” Surgical Clinics of North America, vol. 81, no. 1, pp. 39–70, 2001.
- I. Brook and E. H. Frazier, “Aerobic and anaerobic microbiology in intra-abdominal infections associated with diverticulitis,” Journal of Medical Microbiology, vol. 49, no. 9, pp. 827–830, 2000.
- R. M. Swenson, B. Lorber, T. C. Michaelson et al., “The bacteriology of intra abdominal infections,” Archives of Surgery, vol. 109, no. 3, pp. 398–399, 1974.
- D. A. Eschenbach, T. M. Buchanan, H. M. Pollock et al., “Polymicrobial etiology of acute pelvic inflammatory disease,” The New England Journal of Medicine, vol. 293, no. 4, pp. 166–171, 1975.
- P. A. Mardh, T. Ripa, L. Svensson et al., “Chlamydia trachomatis infection in patients with acute salpingitis,” The New England Journal of Medicine, vol. 296, pp. 1377–1379, 1977.
- R. I. Sweet, D. L. Draper, J. Schachter, J. James, W. K. Hadley, and G. F. Brooks, “Microbiology and pathogenesis of acute salpingitis as determined by laparoscopy: what is the appropriate site to sample?” American Journal of Obstetrics and Gynecology, vol. 138, no. 7, pp. 985–989, 1980.
Copyright © 2016 Paul Tyan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.