Bacteremia With Group a Streptococcus Associated With Herpetic Gingivostomatitis

To The Editors: Group A Streptococcus (GAS) infection has reemerged during the past decade as a public health problem, and increases have been reported in the incidence of bacteremia, necrotizing fasciitis and streptococcal toxic shock syndrome. In children varicella is one of the most important risk factors of severe, invasive GAS disease. 1–3 During the past 24 months 4 children with herpes simplex type I gingivostomatitis and bacteremia caused by GAS were diagnosed in our hospital. We retrospectively collected the demographic, clinical and laboratory data of all children hospitalized in our Department between January, 1999, and December, 2000, who had a discharge diagnosis of herpetic gingivostomatitis. The medical records of an additional two patients with herpetic gingivostomatitis and positive GAS blood cultures who were seen only in the Emergency Department during the same period were also reviewed. A total of 31 children with herpetic gingivostomatitis were hospitalized during the 24-month study period. GAS was isolated from the blood culture in 2 of them (6%), in addition to the 2 children with herpetic gingivostomatitis seen only in the Emergency Department. The total number of children with herpetic gingivostomatitis seen in the Emergency Department and discharge is unavailable. The age of the children ranged from 28 to 52 months. All had a temperature of ≥39.0°C on the fourth day of illness and had mild leukocytosis (11 800 to 15 800 white blood cells/mm 3). The blood cultures that were positive for GAS were drawn on the fourth and fifth days of the illness. HSV type I was isolated from the oral lesions in three of the patients with GAS bacteremia; the fourth patient had a typical clinical presentation of herpetic gingivostomatitis. Three of the four children with GAS bacteremia had a scarlatiniform rash. Bacteremia caused by Kingella kingae has also been reported as a complication of herpetic gingivostomatitis. 4 Studies conducted in the past decade show that K. kingae, like GAS, is a normal component of the oral flora in young children. 5 These organisms presumably invade the bloodstream when the anatomical integrity of the mucosal surface is damaged by the herpetic infection, thereby providing a portal of entry. 4, 5 The isolation from the blood stream of only certain microorganisms that colonize the oral cavity may be explained by their higher degree of pathogenicity which enables them to overcome immunologic system. The immunosuppressive effect of the systemic viral infection may contribute to the process as well. Our search of the relevant English literature yielded no other reports of GAS complicating herpetic gingivostomatitis. We did encounter one study of Russia on seven children who died of invasive streptococcal infection associated with herpetic stomatitis. 6 Our observation suggests that patients with herpetic gingivostomatitis with persistent fever for >3 days may be at risk of bacteremia with GAS, and clinicians should be aware of this possible complication. Jacob Amir, M.D. Moshe Nussinovitch, M.D. Rachel Straussberg, M.D. Liora Harel, M.D.