streptococcus pneumoniae as a cause of...

Infectious Diseases in Obstetrics and Gynecology 1:290-292 (1994)(C) 1994 Wiley-Liss, Inc.

Streptococcus pneumoniae as a Cause of Salpingitis

David Patterson, Celeste M. Johnson, and Gilles R.G. MonifDivision ofLaboratory Medicine and Infectious Diseases, Department of Obstetrics and Gynecology,

Creighton University School of Medicine, Omaha, NE

ABSTRACT

Background: A case ofpneumococcal septicemia associated with laparoscopically documented acutesalpingitis is reported.

Case: Gram-stained cul-de-sac pus revealed gram-positive encapsulated diplococci.Conclusion: This case coupled with reanalysis of prior genital tract involvement in nonpregnant

individuals argues that Streptococcus pneumoniae can mimic gonococcal diseases.(C) 1994 Wiley-Liss, Inc.

KEY WORDSPneumococcal septicemia, acute salpingitis, etiology

treptococcus pneumoniae is not a normal constitu-ent of vaginal bacterial floral’Z; however, given

the opportunity, S. pneumoniae can be a significant2--6pathogen for the female genital tract.

Classically, involvement with the female genitaltract has occurred in conjunction with primary pul-monary disease, engenderment of bacteriurinemia,and subsequent metastatic involvement. 7’8 Morerecently, there is the growing perception that S.pneumoniae, when present within the vaginal floraat the time of parturition or rupture of the fetalmembranes, has the ability to ascend and infect theamnionic sac and secondarily the fetus. 2-6

Genital tract disease due to S. pneumoniae hasbeen reported in nonpregnant females. Isolated casesof spontaneous pneumococcal peritonitis have beendescribed.9, 0 Hadfield et al. reported a case of a46-year-old woman with bilateral tubo-ovarianmasses. Biopsy specimens from both tubes and fromthe wall of the abscesses demonstrated gram-posi-tive, lancet-shaped diplococci which were docu-mented to be S. pneumoniae by immunoperoxidasestaining. Rahav et al. 2 reported a case of post-menopausal pneumococcal tubo-ovarian abscessfrom which S. pneumoniae was recovered.

The purpose of this paper is to report a case ofpneumococcal salpingitis documented by laparo-scopy and comment on its significance in terms ofthe pathogenetic spectrum attributable to S. pneu-moniae as it involves the female genital tract.

CASE REPORTInitially, the patient (age 24) was transferred fromjail to the emergency room because of severe ab-dominal cramping. The diagnosis of systemic lu-pus erythematosis had been previously documented,resulting in the patient’s being placed on pred-nisone, 5 mg/day. The pelvic examination per-formed at that time was normal and she was diag-nosed as having viral gastroenteritis. Two dayslater, because of a suicidal gesture involving excessself-administration of the antidepressant medica-tion fluoxetine hydrochloride (Prozac), the patientwas brought back to the hospital and admitted. Atthat time, she presented as a well-nourished, well-developed black female in no acute distress; how-ever, vital signs included a temperature elevationof 39.8C, pulse 116, respiration 16, and bloodpressure 104/60. Pertinent physical findings in-cluded areas of spotty hyperpigmentation of the

Address correspondence/reprint requests to Dr. Gilles R.G. Monif, Department of Obstetrics and Gynecology, CreightonUniversity School of Medicine, 601 North 30th Street, Suite 4810, Omaha, NE 68131.

Received December 8, 1993Gynecological Case Report Accepted March 28, 1994

S.PNEUMONIAE AS A CAUSE OF SALPINGITIS PATTERSON ET AL.

forehead and malar area, forearms, hands, and feetconsistent with discoid lupus. An abdominal exam-ination was within normal limits. The pelvic exam-ination was deferred. The chest X-ray, sinus films,and a computed tomography (CT) of the head wereall normal. Laboratory evaluation revealed a whiteblood cell (WBC) count of 2,100 with a markedshift to the left, hemoglobin 9.8 g, hematocrit 29%,and platelets 90,000. Her electrolytes, liver func-tion test, and arterial blood gases were within nor-mal limits. Her drug screen was positive for ace-taminophen. A fluorescent antinuclear antibody test(FNA) was positive with an antinuclear antibody(ANA) titer of 1/1,280 and an antinative DNAtiter of 1/80. The C3, C4, and C5 fractions ofcomplement were low. The patient was placed un-der observation, but she continued to run a febrilecourse. Blood cultures, urine cultures, and throatcultures done at the time of admission were nega-tive.On the 3rd hospital day, the patient developed a

sudden onset of severe cramping lower quadrantpain. An abdominal examination revealed diffusedirect and rebound tenderness. Cervical motiontenderness was demonstrated on pelvic examina-tion. Cultures for Neisseria gonorrhoeae, Chlamydiatrachomatis, and wet mount preparations for Trich-omonas vaginalis were negative. Serological testingfor human immunodeficiency virus (HIV)-1 and-2 was negative. The venereal disease research lab-oratory (VDRL) was nonreactive. Consultation wasobtained from the Department of Obstetrics andGynecology. At the time of this examination, thepatient had a temperature elevation of 40.06C,pulse 127, respiration 20, and blood pressure 118/50. Physical examination revealed four-quadranttenderness to direct palpation and rebound tender-ness. The patient refused a pelvic examination. Allblood cultures drawn grew out S. pneumoniae. Apelvic ultrasound revealed a 5 5 2-cm com-plex mass with fluid collection in the cul-de-sac.Consent was obtained and laparoscopy performedunder general anesthesia. Preoperatively, the pa-tient was placed on ampicillin/sulbactam (Unasyn)1.5 g q 6 h for 3 doses. At the time of surgery, thefallopian tubes were noted to be hyperemic andswollen. Purulent material could be expressed fromboth fallopian tubes. Approximately 300-400 cc ofpus was present in the pelvis A gram-stained smearof this material revealed the presence of gram-

positive, well-encapsulated, lancet-shaped diplo-cocci which subsequently demonstrated a positiveQuelling reaction. No organism was isolated; how-ever, the culture techniques were inappropriate forthe recovery of S. pneumoniae. The purulent mate-rial was drained from the cul-de-sac. An incidentalappendectomy was performed. The pathology re-port revealed a normal appendix. Postoperatively,the patient continued to run a fever until 2 daysafter the removal of the Jackson-Pratt (JP) drains.

DISCUSSIONInvolvement of the female genital tract as a meta-static process secondary to maternal septicemia dueto S. pneumoniae is a relatively well-documentedphenomenon in the preantibiotic era. 1,7,8 The oc-currence of cases of chorioamnionitis and/or peri-natal septicemia in the absence of pulmonary in-volvement indicated the possibility of contiguousspread from the vaginal/cervical reservoir and sub-sequent involvement of the female upper genitaltract. 3-6 The fallopian tubes in the 2 cases of spon-taneous peritonitis due to S. pneumoniae in femaleswere described as being swollen and hyperemicwith pus emanating from the ends. 9’1 What wasdescribed is not a specific disease entity (spontane-ous peritonitis) but more probably a progressiveconsequence of salpingitis.

Incrimination of S. pneumoniae as an etiologicalagent in cases of acute salpingitis is probably anunderreported phenomenon. While S. pneumoniaewill grow on 5-7% sheep blood agar culture whenincubated in a CO2 environment, the recovery ofalpha hemolytic streptococci is usually not workedup any further and is often reported as "mixedvaginal flora." Recovery of alpha hemolytic strep-tococci from patients with acute salpingitis needs tobe microbiologically evaluated to exclude the possi-bility that these isolates are S. pneumoniae.

The case in question coupled with those previ-ously identified as being "spontaneous peritonitis"with isolation of S. pneumoniae from women withtubo-ovarian complexes indicates that S. pneumo-niae can function as a primary pathogen for thefallopian tubes and that the entire pathogenic spec-trum previously attributable to N. gonorrhoeae canalso be mimicked by S. pneumoniae.

REFERENCESl. Alzahawi MF, Stack TA, Shrestha TL: Pneumococcal

neonatal colonization and sepsis in association with mater-

INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 291

S.PNEUMONIAE AS A CAUSE OF SALPINGITIS PATTERSON ET AL.

nal genital pneumococcal colonization. Br J Obstet Gy-naecol 95:1198-1988.

2. Oxhorn H: The changing aspects of pneumonia compli-cating pregnancy. Am J Obstet Gynecol 70:1007-1010,1955.

3. Westh H, Skibsted L, Korner B: Streptococcuspneumoniaeinfections of the female genital tract and in the newbornchild. Rev Infect Dis 12:416-422, 1990.

4. Robinson EN Jr: Pneumococcal endometritis and neona-tal sepsis. Rev Infect Dis 12:799-801, 1990.

5. Duff P, Gibbs RS: Acute intraamniotic infection due toStreptococcuspneumoniae. Obstet Gynecol 61:25-27, 1993.

6. DiNello CH, Chaisilwattana R, Fagnant RJ, MonifGRG: Neonatal Streptococcus pneumoniae septicemia andmeningitis. J Reprod Med 35:297-298, 1990.

7. Nuckols HH, Hertig AT: Pneumococcus infection ofthegenital tract in women especially during pregnancy and

the puerperium. Am J Obstet Gynecol 35:782-790,1938.

8. Austrian R, Gold J: Pneumococcal bacteremia with spe-cial reference to bacteremia pneumococcal pneumonia.Ann Intern Med 60:759-760, 1964.

9. Jensen LS: Primary pneumococcal peritonitis. Ann ChirGynaecol 73:95-96, 1984.

10. Gomez RJ, Padilla B, Delgado IA, Dargallo JL, Pe-droviejo C, Elviro J: Streptococcus pneumoniae peritonitissecondary to genital tract infection in a previously healthywoman. Clin Infect Dis 15:1060-1061, 1992.

11. Hadfield TL, Neafie R, Lanoie LO: Tubo-ovarian ab-scess caused by Streptococcus pneumoniae. Hum Pathol 21:1288-1289, 1990.

12. Rahav G, Ben DL, Persitz E: Postmenopausal pneumo-coccal tubo-ovarian abscess. Rev Infect Dis 13:896-897,1991.

292 INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY

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