From Sore Throats to Serious Threats: The Spectrum of Invasive Group A Strep in Kids

Case 1

A 9-year-old male with a past medical history of asthma presented to the ED for evaluation of cough and shortness of breath for three days. Associated symptoms included fevers and decreased oral intake over the last day. Complete review of systems was otherwise negative. A few days prior to the ED visit, the patient was diagnosed with influenza and was prescribed Tamiflu but had not taken the medication.

Upon ED arrival, his vitals were HR 124, BP 84/49 Temp 98.2 F RR 30 SpO2 99% on RA. Physical exam revealed a thin, ill-appearing male who was tachypneic and in moderate respiratory distress. His skin was pale, with delayed capillary refill. The lung exam revealed coarse breath sounds on the right side, but no wheezing. Oxygen saturation was noted to be 90% on room air and the patient was placed on high flow nasal cannula oxygen (HFNC). Shortly after, he was given a bolus of fluids and albuterol with a dose of decadron. Initial VBG showed Ph of 7.15 Co2 of 41 with a lactate of 12.6. Complete blood count and metabolic panel were significant for neutropenia with a white blood cell (WBC) count of 1.00, hyponatremia (130), hypokalemia (3.0), bicarbonate of 13, acute kidney injury with a BUN/Cr of 17/1.5 and a viral swab was positive for influenza B. Chest x–ray showed a right lower lobe opacity and effusion, (shown below) and the patient was treated for pneumonia in the setting of influenza with ceftriaxone, azithromycin and oseltamivir.

The patient was admitted to the Pediatric ICU where he had a rapid decline in clinical status requiring vasopressors and endotracheal intubation and subsequently went into cardiac arrest and expired within eight hours of ED arrival. His blood culture grew Group A Streptococcus by 14 hours.

Case 2

A 6-year-old female, born full-term without complications, up to date on her vaccinations and with no significant past medical history presented to the ED for evaluation of intermittent fevers for one week. Her symptoms were associated with upper respiratory symptoms. She developed right-sided chest and abdominal pain, associated with multiple episodes of non-bloody, non-bilious vomiting, prompting a visit to the ED.

Upon arrival at the ED, T98.9 F, HR 158, BP 88/56, RR 38, and O2 94% on RA. On examination, she was ill appearing and in moderate respiratory distress. Pertinent physical exam findings showed decreased breath sounds on the right and right lower quadrant abdominal tenderness to palpation. She was given acetaminophen, placed on 2 liters of oxygen via nasal cannula with improved oxygenation. Initial chest x-ray showed a right middle and lower lobe pneumonia (image shown below).

Labs showed WBC count of 3 with 56% bands. Other notable labs were a metabolic acidosis with an elevated lactate of 5.6. She received a 20 cc/kg bolus of normal saline, was started on a 75 mg/kg dose of ceftriaxone and was admitted to the PICU.

Upon admission to the PICU, she was started on BiPAP 12/6 with FiO2 of 50%. Her blood culture grew Group A Streptococcus by 5 hours and 36 minutes. She had a complicated PICU course requiring vasopressors, intubation for chest tube placement for worsening pleural effusion, and prolonged antibiotic course. She was able to be weaned to room air after 9 days. The patient was discharged from the hospital on day 17.

Case 3

An 8-year-old female with no significant medical history and up to date on her vaccinations, presented to the emergency department with complaints of back pain and inability to walk or urinate. Patient reported that she had back pain for four days, associated with fevers. On the night prior to ED arrival, she reported decreased sensation to her lower legs and difficulty ambulating. She also had not been able to urinate since the prior evening. She denied any dysuria or hematuria. She had no known trauma. Her mother was giving antipyretics to her at home.

In the ED, her vitals were Temp 98.7F, HR 136, BP 123/82, RR 24, and O2 99% on RA. Her physical exam showed a well appearing interactive female, lying flat on the stretcher. Pertinent exam findings included decreased sensation to her left leg compared to her right and diminished below the level of the knees. She was unable to raise her legs against gravity and had diminished lower extremity reflexes. There was no spinal tenderness on her back exam but pain with attempting to sit up in bed. Point of care ultrasonography showed 300cc of urine in her bladder. She had no skin changes and the remainder of her exam was normal.

Lab findings showed a WBC of 12 and a grossly normal complete metabolic panel. She had an ESR of 99 and CRP of 244. A foley was placed and urinalysis results were negative for infection.

She was sent for an emergent MRI of the brain and spinal cord which showed “extensive dorsal multiloculated collection, likely abscess, most pronounced from T1 through T6 with extensive phlegmonous enhancement of the remaining thoracic epidural space with cord compression.”

The patient had emergent laminectomy from T1-T6 for abscess drainage. The urine and blood cultures were negative but cultures from the epidural abscess grew Group A Streptococcus. She had a prolonged hospital course but was ambulating with assistance by post-operative day 2 and was discharged to a children’s rehabilitation facility. The patient was discharged from rehabilitation without any focal neurological deficits and is back to her baseline.

Discussion

Invasive Group A Streptococcus (iGAS) bacteremia in pediatric patients is a critical condition that necessitates prompt recognition and intervention by emergency medicine physicians. Ill-appearing children presenting with this infection often exhibit a spectrum of symptoms that can overlap with other less severe conditions, making early and accurate diagnosis challenging but essential for improving outcomes.

Children with iGAS bacteremia typically present with nonspecific symptoms such as fever, irritability, lethargy and poor feeding, which are common in many pediatric illnesses. However, certain clinical signs can raise suspicion for a more severe infection. These include a rapid progression of symptoms, severe pain, signs of septic shock or the presence of a preceding skin or soft tissue infection. Recognizing these red flags is crucial for emergency physicians, who must maintain a high index of suspicion for iGAS, especially in ill-appearing children.

Early recognition of iGAS bacteremia is paramount because delays in diagnosis and treatment can lead to severe complications such as septic shock, multi-organ failure and death. Empirical antibiotic therapy should be initiated promptly in children suspected of having invasive bacterial infections and blood cultures should be obtained to confirm the diagnosis and guide further treatment. The rapid initiation of appropriate antibiotics has been shown to significantly improve outcomes in children with iGAS bacteremia.

Management of iGAS bacteremia involves not only antibiotic therapy, but also supportive care tailored to the severity of the child’s condition. This may include intravenous fluids, vasopressors for septic shock and intensive care monitoring. Emergency physicians play a pivotal role in the initial stabilization and coordination of care for these critically ill patients. Multidisciplinary collaboration with pediatric infectious disease specialists, intensivists and surgeons is often necessary, particularly in cases complicated by necrotizing fasciitis or other deep-seated infections.

For emergency medicine physicians, familiarity with the presentation and management of iGAS infections is essential for several reasons:

1. Timely Diagnosis: Quick and accurate diagnosis can significantly reduce the morbidity and mortality associated with iGAS infections.

2. Appropriate Use of Resources: Early identification and treatment can help in the appropriate allocation of resources, such as intensive care beds and surgical interventions.

3. Education and Awareness: Increasing awareness and education among emergency medical staff about the signs and symptoms of severe iGAS infections can improve patient outcomes and reduce the risk of misdiagnosis.

The recognition and management of ill-appearing pediatric patients with iGAS bacteremia are critical competencies for emergency medicine physicians. By maintaining a high index of suspicion, initiating timely and appropriate treatment and collaborating with multidisciplinary teams, emergency physicians can significantly improve outcomes for these vulnerable patients. This case series underscores the importance of vigilance and expertise in the emergency department setting to effectively combat the serious threat posed by invasive Group A Streptococcus infections.

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