eMedicine Specialties > Infectious Diseases > Bacterial Infections

Streptococcus Group D Infections

Author: John W Downs, MD, Resident Physician, Department of Medicine, Tripler Army Medical Center
Coauthor(s): Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada; Tomas Michael Ferguson, MD, Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Tripler Army Medical Center
Contributor Information and Disclosures

Updated: Jan 23, 2009

Introduction

Background

Streptococcus group D infections in humans are most often associated with bacteremia, with or without endocarditis. Other less-common infections involving group D streptococci include urinary tract infections, meningitis, neonatal sepsis, spontaneous bacterial peritonitis, septic arthritis, and vertebral osteomyelitis. Traditionally, group D streptococcal infections have predominantly been caused by Streptococcus bovis, but recent taxonomy changes have produced confusion among clinicians.

S bovis is well-established in the literature as a cause of bacteremia and endocarditis and has a well-known association with gastrointestinal malignancy. For simplicity, S bovis is the terminology used throughout this article.

Pathophysiology

The portal of entry for S bovis bacteremia is the gastrointestinal tract, with the urinary tract, the hepatobiliary tree, or the oropharynx acting as the source in some cases. S bovis bacteremia, with or without endocarditis, is strongly associated with an underlying malignancy or premalignant lesions of the colon. S bovis has also been isolated more frequently from the stools of patients with such malignancies.

Associations with nonmalignant diseases of the colon have also been reported. A similar relationship between bacteremia (or endocarditis) and chronic liver disease has been established.1 In rare cases, gastric cancer has been found upon investigation following S bovis bacteremia.2 Every patient with S bovis bacteremia, with or without endocarditis, should undergo evaluation for gastrointestinal malignancy.

Frequency

United States

Isolation of S bovis from microbiology specimens, particularly blood cultures, is uncommon. The SENTRY Antimicrobial Surveillance Program in the United States does not list group D streptococci among the 10 most common organisms that cause bloodstream infections, accounting for no more than 1% of all cases.3 According to the SCOPE Program, streptococci accounted for 6% of all blood culture isolates among 30 US hospitals, with S bovis accounting for 2.4% of those streptococci.4

Despite these findings, the microorganisms most commonly implicated as etiologic agents in subacute infective endocarditis occurring on native valves in patients who were not intravenous drug users were Streptococcus viridans and S bovis. Since 1997, a review of the International Collaboration on Endocarditis merged database (ICE-MD) found that S bovis accounted for 16.7% of all streptococcal infective endocarditis cases reported in the United States.5 However, this study reported findings from only two US hospitals.

International

SENTRY data indicate that S bovis was isolated in 1.3% and 6.9% of streptococcal bloodstream infections in Canada and Latin America, respectively. Kupferwasser et al compared patients with S bovis endocarditis with patients with endocarditis secondary to other causative microorganisms. In this German study, 177 cases of definite infective endocarditis were reported between 1983 and 1996, with 22 cases (12.5%) caused by S bovis.6

More-recent studies have shown an increasing proportion of infective endocarditis caused by S bovis, particularly in France and neighboring areas of southern Europe. An analysis of 559 cases of infective endocarditis in France in 1999 found that 25% were caused by S bovis.7 A Spanish study recently reported similar findings.8

Mortality/Morbidity

  • Morbidity: A study by Kupferwasser et al showed that S bovis endocarditis is a severe infection. The duration of fever and the increased acute-phase reactants after the onset of treatment were longer than with infective endocarditis caused by other bacteria. Involvement of multiple valves and valvular damage resulting in moderate-to-severe regurgitation were also more common. Embolic events were less common and correlated with the smaller sizes of S bovis vegetations observed on transesophageal echocardiograms. Gastrointestinal lesions were observed in nearly 50% of patients with S bovis endocarditis.6
  • Mortality: Mortality rates from the same study were 45% for S bovis endocarditis and 25% for non– S bovis endocarditis. This is higher than the 7.5-38% mortality range reported previously. The increased mortality was related to the virulence of S bovis and to a more common occurrence of underlying extracardiac disease of which patients died during follow-up care.6

Race

Streptococcus group D infections have no known racial predilection.

Sex

Streptococcus group D infections have no reported sexual predilection.

Age

Nearly all individuals with S bovis endocarditis are older than 50 years, with a mean age of 67 years and age range of 49-76 years. This once meant that patients with S bovis endocarditis were on average older than patients with endocarditis caused by other species. However, the mean age for all cases of endocarditis has recently increased, making patients with S bovis endocarditis generally no older than those with endocarditis from other causes.9

Clinical

History

Meningitis, peritonitis, septic arthritis, urinary tract infections, and neonatal sepsis due to group D streptococci do not have specific clinical features.

  • Group D streptococcal endocarditis
    • Subacute endocarditis with persistent fever lasting days or weeks
    • Associated with nonspecific symptoms of systemic lupus erythematosus, including anorexia, weight loss, fatigue, night sweats, and weakness
  • Group D streptococcal bacteremia
    • Fever
    • Only possible to distinguish from endocarditis with patient history and echocardiography

Physical

Group D streptococcal bacteremia manifests as fever without localizing signs.

The following are the physical findings of group D streptococcal endocarditis:
  • A minority of patients with group D streptococcal endocarditis have heart murmurs.
  • Classic peripheral signs occasionally observed include splinter hemorrhages, conjunctival petechiae, Osler nodules, Janeway lesions, and Roth spots. At least one of these manifestations occurs in approximately 50% of cases.
  • Embolic phenomena may include hematuria, neurologic manifestations, and splenomegaly.
  • Renal failure may be present and is caused by an immune-complex glomerulonephritis.
  • If cerebral hemorrhage is observed, it is a consequence of a ruptured mycotic aneurism.

Causes

  • Group D streptococci, along with other catalase-negative, gram-positive cocci, belong to the family Streptococcaceae. Group D streptococci may also be referenced as the S bovis–Streptococcus equinus complex.10 S bovis has recently been reclassified as Streptococcus gallolyticus, but references to S bovis remain prevalent in the clinical literature . S equinus is almost never isolated from human specimens.
  • Group D streptococci share many features with enterococci. In the mid 1980s, Streptococcus faecalis, Streptococcus faecium, and others were reclassified under the newly created genus Enterococcus.
  • Similar to enterococci, S bovis possesses the group D lipoteichoic acid antigen in its cell wall. It also shares the ability to hydrolyze esculin in the presence of bile. Unlike enterococci, S bovis fails to grow in broth containing a concentration of 6.5% sodium chloride and is negative for the pyrrolidonyl arylamidase reaction.
  • S bovis was traditionally differentiated into two biotypes, termed S bovis or S bovis I (now termed S gallolyticus subspecies gallolyticus) and S bovis variant or S bovis II. S bovis II was further differentiated into 2 sub-biotypes, S bovis II/1 (now termed Streptococcus infantarius) and S bovis II/2 (now termed S gallolyticus subspecies pasteurianus or Streptococcus pasteurianus).
  • In a study of patients with S bovis bacteremia, Ruoff et al demonstrated the following:11
    • S bovis I is most often associated with endocarditis and/or malignant or premalignant colonic lesions.
    • S bovis II (mainly sub-biotype II/1) is most often associated with a bacteremia of hepatobiliary origin.

More on Streptococcus Group D Infections

Overview: Streptococcus Group D Infections
Differential Diagnoses & Workup: Streptococcus Group D Infections
Treatment & Medication: Streptococcus Group D Infections
Follow-up: Streptococcus Group D Infections
References
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References

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Further Reading

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Keywords

Streptococcus group D infections, streptococcal group D infections, group D Streptococcus, group D streptococci, Streptococcus bovis–Streptococcus equinus complex, Streptococcus bovis, Streptococcus gallolyticus, Streptococcus infantarius, Streptococcus pasteurianus, S bovis–S equinus complex, S bovis, S gallolyticus, S infantarius, S pasteurianus, infective endocarditis, infectious endocarditis, bacterial endocarditis, endocarditis, neonatal sepsis, streptococcal bloodstream infections, S bovis bacteremia, S bovis endocarditis

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Contributor Information and Disclosures

Author

John W Downs, MD, Resident Physician, Department of Medicine, Tripler Army Medical Center
John W Downs, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christian P Sinave, MD, Associate Professor, Department of Medical Microbiology and Infectious Diseases, University of Sherbrooke, Canada
Christian P Sinave, MD is a member of the following medical societies: American Society for Microbiology and Canadian Infectious Disease Society
Disclosure: Nothing to disclose.

Tomas Michael Ferguson, MD, Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Tripler Army Medical Center
Tomas Michael Ferguson, MD is a member of the following medical societies: American College of Physicians, Armed Forces Infectious Diseases Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Pranatharthi Haran Chandrasekar, MD, Director of Infectious Disease Fellowship, Professor, Department of Internal Medicine, Harper Hospital, Wayne State University School of Medicine
Pranatharthi Haran Chandrasekar, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

John L Brusch, MD, FACP, Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance
John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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