JCDR - Register at Journal of Clinical and Diagnostic Research
Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X
Case Report DOI : 10.7860/JCDR/2013/4852.3034
Year : 2013 | Month : Jun | Volume : 7 | Issue : 6 Full Version Page : 1143 - 1144

Septic Arthritis caused by Group A Streptococcus in Newborn: An Unusual Presentation

Sivaraman Umadevi1, Arunava Kali2, Srirangaraj Sreenivasan3, S. Pramodhini4, M.V. Pravin Charles5

1 Professor, Department of Microbiology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India.
2 Assistant Professor, Department of Microbiology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India.
3 Associate Professor, Department of Microbiology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India.
4 Assistant Professor, Department of Microbiology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India.
5 Assistant Professor, Department of Microbiology, Mahatma Gandhi Medical College & Research Institute, Pondicherry, India.

NAME, ADRESS, E-MAIL ID OF THE CORESPONDING AUTHOR: Dr. Sivaraman Umadevi, Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pillaiyarkuppam, Pondicherry - 607402. India.
Phone: 9842173519
E-mail: drumadevis@yahoo.com

Streptococcal sepsis in neonates is a potentially lethal condition. A wide spectrum of clinical presentations has been often reported in Group B Streptococcal infections in neonates. Bone and joint infections which are caused by Group B Streptococcus are also encountered frequently, but they have not yet been reported in case of Group A Streptococcal infection in neonates. Here, we are reporting a case of septic arthritis and late onset neonatal sepsis which were caused by Group A Streptococcus in a full term, healthy baby.



Neonatal sepsis is a clinical syndrome of blood stream infections, with systemic signs of sepsis occurring in the first month of life. As compared to the pre-antibiotic era, the frequency of the neonatal sepsis which is caused by Group A Streptococcus (GAS) has decreased drastically and its complications are also showing a decreasing trend. The mortality which is caused by the GAS infection in neonates is uncommon nowadays. However, Group B Streptococcus (GBS) has emerged as a prominent aetiology in neonatal infections [1]. Although bone and joint infections in newborns are not an infrequent observation in the GBS infection, they are a rarity in case of GAS. Septic arthritis which is caused by GAS, is mainly reported in adults rather than in neonates. As per a recent prospective surveillance study, the estimate of Group A streptococcal septic arthritis was 7.4% in the Indian population [2]. Negative blood cultures in neonatal septic arthritis are reported in 40% of the cases, followed by 33% and 20% cases, which are attributed to gram negative bacteria viz., Klebsiella pneumoniae, Escherichia coli and Enterobacter and gram positive pathogens viz., Staphylococcus aureus, GBS and Streptococcus pneumonia in India respectively [3]. Here, we are reporting the clinical history of an unusual case of septic arthritis and late onset neonatal sepsis which was caused by GAS.


A 26 years old, second gravida lady delivered a 3.2 kg term healthy male baby by caesarean section. The baby had a breech presentation and meconium stained liquor and shortly after delivery, he developed jaundice, which responded well to phototherapy. On the 8th day of his life, his mother complained of a swelling on his right elbow and reduced movements of the right forearm. On examination, the diffuse swelling over the right elbow was found to be tender, along with signs of inflammation. Although there was no history which was suggestive of a pulled elbow injury, it was initially diagnosed as a dislocation of the elbow. It was not associated with the typical signs of sepsis like thermal instability, haemodynamic instability, bradycardia, and respiratory discomfort [4] and the haematological parameters were also within normal limits. However, the CRP value was high (3.6 mg/dl).

Ultrasonography revealed fluid accumulation in the affected elbow joint, which on aspiration was found to be serosanguinous and on direct microscopic examination, displayed few gram positive cocci in pairs and chains, amongst plenty of neutrophils. Both the blood culture and the pus aspirate from the elbow joint displayed the same strain of beta haemolytic streptococci which showed the same antibiotic sensitivity pattern. The isolate was identified as Streptococcus pyogenes by conventional method and it was further confirmed by serogrouping with the use of the Streptex Streptococcal grouping kit (Oxoid, United Kingdom, Lot Number 1083582, manufacturing date Feb, 2012). The signs of inflammation subsided after 2 days of parenteral ampicillin, cloxacillin and amikacin therapy. However, the swelling persisted. Incision and drainage of the pus and a second blood culture which was done on the 10th postnatal day, were found to be sterile. The postoperative period was uneventful and the wound was healthy. Oral ampicillin and erythromycin was started and baby was discharged on the 19th postnatal day.


Neonatal sepsis is a dreadful complication which contributes up to 12% of the total neonatal deaths in the Indian population [5]. Streptococcus pyogenes is a major cause of both puerperal as well as neonatal sepsis, especially in the developing countries. As per the WHO report, it was the cause of the bacteraemia in neonates in 0.55 per 1,000 live births [1]. GAS has also been reported to constitute about 21% of the cases of late onset neonatal sepsis in the Indian subcontinent [6]. However, over the past few decades, it has been replaced by GBS, which has emerged as a more successful pathogen, as a result of the asymptomatic colonization of the birth canal in pregnant women, which can be seen in as high as 35% women [7]. The Streptococcal sepsis in neonates occurs in two setups. The early onset sepsis manifests within the first week of life and the infection is acquired during the antenatal period through an ascending infection or intranatally from an exposure to the vaginal flora, while in late onset sepsis, the infection is mainly transmitted from an external source, especially from caregivers [8]. In this case also, it was likely that the baby had acquired the GAS infection postnatally, as the high vaginal swab for the antenatal GBS screening of the mother was negative.

The neonatal colonization by GAS was reported to be 19% in one study [9]. Although, S. pyogenes has been reported to cause neonatal sepsis, meningitis, skin infections, the toxic shock syndrome and unusual presentations like parotitis, it has not yet been reported to cause septic arthritis in neonate [913]. It is predominantly the result of a haematogenous spread and seeding in the synovial membrane. Monoarthritis is typical. However, multifocal GAS polyarthritis has also been reported [14]. The importance of serogrouping and sensitivity testing is of particular interest in cases of pregnant women with penicillin allergy, since erythromycin and clindamycin resistances are frequently prevalent among the GBS strains [8]. In this case, the diagnosis was challenging, since the classical signs of sepsis were absent and consequently, it was initially considered as a case of elbow joint dislocation. In such cases, the laboratory parameters have vital roles in the diagnosis. A high CRP level was the initial parameter which suggested a probable infective aetiology. Streptococcal sepsis frequently causes severe sepsis in newborns, with high mortality, particularly in premature neonates [7]. As there was no prematurity in this case, a prompt diagnosis and an appropriate treatment resulted in an uneventful resolution of the sepsis and the arthritis.


The GAS sepsis in neonates is potentially lethal and it also carries the risk of an outbreak in nurseries due to hospital cross infections. However, it is amenable to treatment if it is diagnosed early. The clinical presentation may be unique and it may be confused with GBS. Sero-grouping and susceptibility testing should be done for all the isolates, for a proper selection of antibiotics, especially in penicillin allergic patients.


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