The -hemolysin of Streptococcus agalactiae is a major virulence factor; consequently, nonhemolytic strains rarely cause infections. We report on a case of neonatal sepsis caused by a strain displaying heterogeneous hemolysin expression. It was detected by the simultaneous isolation of hemolytic and nonhemolytic colonies from cultures of the infant's blood.
CASE REPORTA term neonate was born at 41 weeks of gestation weighing 4,300 g. Due to a failure of adequate labor progress and pathological cardiotocographic readings, the infant was delivered by vacuum extraction. During delivery green amniotic fluid was noted. The Apgar score was 7/9/9, and the umbilical arterial pH was 7.17. Due to progressing signs of dyspnea, a gray skin color, a prolonged capillary refill time, and a further fall in the pH to 7.02, the child was transferred to the neonatal intensive care unit of the Pediatrics University Clinics 2 h after birth. The prenatal group B streptococcus colonization status of the mother was unknown. At admission, a blood sample for aerobic culture (PLUS Pediatric; BD, Heidelberg, Germany) was obtained and treatment with mezlocillin (200 mg/kg of body weight /day) and gentamicin (5 mg/kg/day) was initiated for suspected neonatal sepsis. The infant was negative for C-reactive protein (CRP) at admission, but the interleukin-8 level was elevated to 1,517 ng/liter. The aerobic blood culture bottle registered positive after 24 h of incubation in an automated blood culture system (Bactec 9240; BD). Microscopic analysis revealed the presence of gram-positive cocci growing in chains and displaying a typical streptococcal morphology. Following subculture on 5% sheep blood agar plates and overnight incubation at 35°C, the growth of two different colony types was detected. Gray colonies surrounded by a small zone of betahemolysis were present, as were colonies of the same morphology lacking any type of hemolysis. Both colony types were catalase negative. Further species identification of both strains was achieved biochemically with the API Strep system (BioMerioeux) and resulted in the detection of Streptococcus agalactiae isolates with identical API profiles. The isolate identities were confirmed by CAMP testing and serological testing with the Streptex system (Murex Streptex; Abbott, Wiesbaden, Germany), which showed the presence of the group B streptococcal antigen in both strains.During the next days the infant's clinical situation quickly improved. The CRP concentration reached a maximum of 19.7 mg/liter. The cerebrospinal fluid did not reveal any signs of meningitis, and the child was discharged on day 4 in excellent clinical condition.To assess the colonization status of the mother, a vaginal swab was obtained postpartum and was cultured in selective LIM broth, as recommended by CDC guidelines (11). Typical beta-hemolytic colonies were detected, and species identification revealed S. agalactiae. Despite a thorough inspection of the subcultures for evidence of nonhemolytic S. agalactiae colonies, only the beta-hemoly...