Streptococcus suis-Related Prosthetic Joint Infection and Streptococcal Toxic Shock-Like Syndrome in a Pig Farmer in the United States

Abstract

e Streptococcus suis is an emerging swine-associated zoonotic agent that can cause meningitis and septicemia in humans. We present, to our knowledge, the first case of S. suis arthroplasty infection and streptococcal toxic shock-like syndrome due to an nonencapsulated serotype 5 strain in North America. CASE REPORTA 74-year-old man with a history of non-Hodgkin's lymphoma, in remission, and splenectomy was transferred to our institution for management of septic shock. The patient was a pig farmer who had undergone right total hip arthroplasty (THA) in 1993 and left THA in 1996, both for osteoarthritis. In January 2010, he had undergone a revision left hip arthroplasty for polyethylene wear.He was well until February 2011, when he developed acute severe left hip pain while working on his farm. Other symptoms included a few days of nausea, vomiting, and diarrhea. A syncopal episode prompted evaluation at a local hospital, where he was found to be febrile (39.4°C), tachypneic (24 breaths/min), and hypotensive (89/45 mm Hg). He received 6 liters of fluids and norepinephrine and was transferred to our institution, where he was hypotensive, with metabolic acidosis (lactate concentration of 6.7 mmol/liter), acute renal failure, leukopenia (white blood cell [WBC] count of 1.4 ϫ10 9 /liter), and disseminated intravascular coagulopathy. He had a diffuse erythematous rash on his chest, back, and neck, and severe pain was elicited with movement of the left hip.Due to severe respiratory and metabolic acidosis, he was placed on mechanical ventilation. Intravenous vancomycin and meropenem were empirically started. A radiograph of the hip showed a left trochanteric fracture with cerclage and lucency of the acetabular component (Fig. 1). An ultrasoundguided arthrocentesis of the left hip was attempted, but no fluid was obtained. Five milliliters of sterile normal saline was injected, and 0.5 ml was withdrawn for culture only. Blood and aspirated saline submitted to the Clinical Microbiology Laboratory, Mayo Clinic, Rochester, MN, grew alpha-hemolytic Gram-positive cocci in pairs that formed mucoid colonies (Fig. 2) that were catalase negative, optochin resistant, and bile insoluble. The isolate was identified as Streptococcus suis by partial 16S rRNA gene sequencing. It was susceptible to penicillin (MIC, Յ0.06 g/ml), ceftriaxone (MIC, Յ0.5 g/ml), and vancomycin (MIC, Յ1.0 g/ml) and resistant to erythromycin (MIC, Ͼ0.5 g/ml) (as there are currently no breakpoints for S. suis by the Clinical and Laboratory Standards Institute guidelines, breakpoints for viridans group streptococci were used). On hospital day 3, irrigation and debridement with polyethylene liner exchange were performed on the left hip. Intraoperative frozen sections showed chronic inflammation; periprosthetic tissue cultures were negative. Cerebrospinal fluid showed 26 mg/dl of protein, 73 mg/dl of glucose (serum glucose, 109 mg/dl), 1 leukocyte/l (76% lymphocytes), and negative bacterial culture. A transesophageal echocardiogram was negative for heart valve vege...

Fatal case of bacteremia caused by Streptococcus suis in a splenectomized man and a review of the European literature

“…Misidentification of S. suis is very common: this bacterium is frequently misidentified as Streptococci viridans [14] and has also been misidentified as Streptococcus bovis, Streptococcus pneumoniae, Streptococcus faecalis, and Streptococcus acidominimus [2,6,21,83]. Misidentification of S. suis also has been reported in Canada, which raises suspicion that human S. suis infections might be underdiagnosed in North America [84,85]. In the report by Tarini et al, a previously healthy 50-year-old man was admitted to one of the district hospitals in Bali Province, Indonesia, due to meningitis.…”

Serotype- and virulence-associated gene profile of <i>Streptococcus suis</i> isolates from pig carcasses in Chiang Mai Province, Northern Thailand

“…Although serotype 2 is the most prevalent type recovered from humans, zoonotic cases involving serotypes 1, 4, 5, 14, 16, 21 and 24 have also been reported [ 1 , 5 , 8 , 12 , 13 , 15 ], with serotypes 5 and 24 being the most recently reported cases in Thailand [ 12 ]. Serotype 5 strains have also been isolated from humans in U.S.A. and Europe [ 7 , 8 ]. Serotypes 4 and 5 were identified in our study, and their numbers were similar to those found for serotype 2, suggesting their long-term existence in this area and their potential to cause disease in both swine and humans.…”

First human case report of sepsis due to infection with Streptococcus suis serotype 31 in Thailand

“…The strain isolated from this case belonged to ST221 in CC221/234. To the best of our knowledge, only two other unencapsulated strains have been recovered from human cases [ 3 , 34 ], although unencapsulated S. suis has frequently been isolated from pigs [ 1 , 35 ]. It is particularly interesting that CC221/234 did not contain any serotype 2 strains, but rather only serotype 24 strains (ST221 and ST234) ( http://ssuis.mlst.net/sql/burstspadvanced.asp ).…”