A Case of Urethritis Due to Streptococcus pneumoniae

To the Editor: Streptococcus pneumoniae is a primary pathogen of many human infections, such as pneumonia, otitis media, sinusitis, and bacterial meningitides. It is a very rare pathogen of genital infections among women, and only one case of urethritis in a male has been reported to date, which occurred after an orogenital contact.1 This article presents a case of pneumococcal urethritis, which was probably transmitted during sexual intercourse as a result of vaginal colonization with S. pneumoniae. In March 2007, a 43-year-old man who had multiple sex partners was admitted to our infectious disease clinic. The major complaints of the patient were a 1-month history of dysuria and a light brown, semitranslucent urethral discharge after urinating. These symptoms were increased when he had an erection. During the first examination, no significant findings were recorded. Biochemical and hematologic tests were normal. Immunologic tests were negative for human immunodeficiency virus and syphilis. A bacterial culture and Gram stain of the draining exudate were performed. Several lancet-shaped, Gram-positive diplococci and 500 to 600 neutrophils/mL were observed in the Gram stain of the urethral fluid. After an overnight incubation, mucoid, α-hemolytic streptococcal colonies grew in blood agar. The isolate was positive in the bile solubility test and susceptible to optochin, penicillin, azithromycin, and cotrimoxazole, and intermediately resistant to ciprofloxacin in a disk diffusion antibiogram. The BD BBL Crystal test (Becton-Dickinson) confirmed the pathogen as S. pneumoniae. The patient was successfully treated with oral amoxicillin (2 × 1 g) for 1 week. The patient’s wife did not report any urogenital complaint. A gynecologic examination and vaginal culture yielded normal findings. His second sexual partner declared dyspareunia and an increased vaginal discharge (brownish yellow and sticky) for some months. A few mucoid S. pneumoniae colonies grew from a swab culture of the vaginal fluid; however, she declined a comprehensive medical evaluation because of social concerns. The frequency of urethral infection with S. pneumoniae is not known.1 The organism has been reported in rare instances as a pathogen of the female genital tract.2 Pneumococcal infection of the female internal genital organs may give rise to endometritis, salpingitis, pelvic inflammatory disease, and abscesses, and may be complicated by diffuse peritonitis.2,3 This possibility may be increased by a predisposing factor, i.e., use of an intrauterine device, the postpartum state, or instrumentation of the uterine cavity.2–4 Additionally, neonatal sepsis, meningitis, and endophtalmitis have been reported as a result of maternal vaginal colonization with S. pneumoniae.5,6 The recovery of S pneumoniae from a genital infection may be associated with a primary invasion or may be secondary to pneumococcal infection elsewhere.2 As the pneumococcus is a commensal of the upper respiratory tract, orogenital sexual contact has been suggested to be responsible for direct inoculation of the organism to the male urethral mucosa.1 At this point, there are analogies to meningococcal urethritis that have been reported.7,8 However, in the presented case, the patient and his partners did not report such a practice at any time. There is no clear evidence the patient’s urethral infection was acquired during sexual contact. However, because the organism was recovered from both the patient and his partner’s genital cultures, we have suggested that the pathogen was most likely sexually transmitted. Intrauterine device use by the extramarital sexual partner caused a frequent lapse of condom use. Therefore, we thought that this might facilitate the inoculation. On the other hand, regular use of condoms probably protected his wife from the pneumococcal inoculation. In conclusion, although S. pneumonia is not a frequently encountered genital pathogen, this report highlights its ability to cause urethritis as a result of possible sexual transmission in the course of natural sexual intercourse.