Complicated Head and Neck Infections Caused by Streptococcus constellatus at the End of the COVID-19 Pandemic: A Case Series

İngilizce (OpenAlex)

To the Editors: Following the canceling of COVID-19 pandemic restrictions, an increased number of invasive infections caused by Streptococcus pyogenes and Streptococcus pneumoniae have been reported.1,2 However, there is a relative paucity of data regarding the invasive infections due to other Streptococci species. Herein, we report a case series of complicated head and neck infections caused by Streptococcus constellatus at the end of the COVID-19 pandemic. Between October 2021 and March 2022, we observed an apparent increase in the frequency of severe head and neck infections caused by S. constellatus in our institution. We followed up 5 consecutive cases aged between 6 and 15 years in a 6-month period (Table 1). TABLE 1. - Clinical Characteristics of Patients With Head and Neck Infections Caused by Staphylococcus constellatus Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Age (year) 10 6 15 15 14 Gender Male Female Female Male Male Underlying disease – Epilepsy, cerebral palsy – – – Oral hygiene/tooth decay Poor/− Poor/+ Poor/+ Poor/− Poor/+ History of preceding sinusitis Yes – – Yes – Clinical presentation Fever, headache, behavioral changes, seizures Fever, respiratory distress, neck swelling Limited neck movements, right buccal swelling, trismus, difficulty in swallowing Fever, headache, right periorbital swelling Swelling, pain and tenderness in the right mandible corner Diagnosis Frontal sinusitis, subdural empyema Left branchial cleft cyst abscess Right submandibular space abscess, mandibular osteomyelitis Right preseptal cellulitis with eyelid abscess, subdural empyema Right facial abscess PICU admission Yes Yes – – – SARS-CoV-2 RT-PCR (preoperative) Positive, asymptomatic Negative Negative Negative Negative White blood cell count at admission (×103/µL) 24 × 103/µL (%78 neutrophil) 20 × 103/µL (%80 neutrophil) 18 × 103/µL (%72 neutrophil) 8.8 × 103/µL (%66 neutrophil) 19 × 103/µL (%78 neutrophil) CRP at admission (mg/L) 183 318 235 73 60 Abscess culture S. constellatus S. constellatus S. constellatus S. constellatus S. constellatus Blood culture – S. constellatus, Staphylococcus epidermidis S. constellatus – – Antibiotic treatment IV ceftriaxone (100 mg/kg) and vancomycin (60 mg/kg) IV ceftriaxone (100 mg/kg/day) and clindamycin (40 mg/kg/day) IV ampicillin-sulbactam (200 mg/kg/day) and clindamycin (40 mg/kg/day) IV ceftriaxone (100 mg/kg/day) and vancomycin (60 mg/kg/day) IV clindamycin (40 mg/kg/day) Duration of antibiotic treatment (day) 42 14 30 30 14 Surgical treatment Neurosurgical intervention (empyema drainage 3 times) Otolaryngological intervention (abscess drainage) Otolaryngological intervention (abscess drainage) Otolaryngological, oculoplastic, and neurosurgical interventions (abscess and empyema drainage 3 times) Otolaryngological intervention (abscess drainage) Length of hospital stay (day) 42 21 30 30 14 CRP indicates C-reactive protein; IV, intravenous; PICU, pediatric intensive care unit; RT-PCR, real-time polymerase chain reaction. We reviewed the database of our microbiology laboratory for S. constellatus-positive cultures between January 2011 and September 2021 and could not find a positive culture. Diagnosis of head and neck infections was confirmed with contrast-enhanced computed tomography or magnetic resonance imaging. All patients underwent surgical interventions in combination with long-term antibiotic therapy. Abscess and blood culture results are shown in Table 1. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry using the VITEK MS system (Biomeriux, France) was used for bacterial identification. Antimicrobial susceptibility testing was performed using Vitek 2 AST-ST03 (Biomeriux, France) cards. All S. constellatus isolates were susceptible to penicillin G (minimum inhibitory concentrations ≤0.125 mcg/mL). All 5 patients recovered uneventfully. The Streptococcus anginosus group (SAG) is a subgroup of viridans streptococci that consists of 3 distinct species: S. anginosus, Streptococcus intermedius and S. constellatus. These organisms are part of the normal human flora colonizing the oropharynx, gastrointestinal, and genitourinary tracts.3 The Centers for Disease Control and Prevention recently reported an increase in pediatric streptococcal intracranial infections following the onset of the COVID-19 pandemic.4 The SAG organisms have been increasingly reported in children with sinogenic and otogenic intracranial infections in recent years.3 The reasons for this increase are unclear. The widespread use of pneumococcal conjugate vaccines has changed the microbial etiology of complicated sinusitis.3 Additionally, the application of more modern microbiological techniques such as matrix-assisted laser desorption/ionization time-of-flight mass spectrometry or next-generation sequencing has increased the identification of SAG species. Lastly, the temporal association between COVID-19 pandemic and an increased number of complicated head and neck infections at our institution suggests that there may be a relationship. Speculative mechanisms of SARS-CoV-2 predisposing to complicated head and infections include (1) disruption of the respiratory microbiota and (2) alteration of the respiratory tract and oropharyngeal bacterial flora due to masking and social distancing. Prolonged use of face masks can lead to oral health problems, which are being termed “mask mouth syndrome,” including bad breath, dry mouth, gingivitis, and eventually tooth decay.5 In our case series, all 5 patients had poor oral hygiene and 2 patients had tooth decay. Since there is a known association between S. constellatus and dental plaque and periodontal diseases, this mechanism may be one of the reasons in our cases. Further studies are necessary to understand the reasons of the increased incidence or mechanisms of the S. constellatus infections.