November 2000
LEBANON, N.H. - Group A streptococcus (GAS) perineal disease is primarily a disease of early childhood. Cases generally cluster in the preschool and early school-age group. Results of a study recently published in Pediatrics indicate that the disease may be more common than previously thought.
Researchers here suggest that pediatricians be alert for this phenomenon, especially when increased GAS diagnosis occurs in the community and among preschool and school-aged children with perineal, gastrointestinal or genitourinary symptoms or with psoriatic lesions. While most perineal disease is mild if diagnosed early, perianal disease can result in significant problems with stool retention, constipation and fecal incontinence and can result in invasive procedures or accusations of sexual abuse.
GAS perineal disease "has many different manifestations," said Nancy P. Mogielnicki, PA, MPH, associate professor of pediatrics and community and family medicine at Dartmouth Medical School here.
Perianal disease should be suspected when a parent reports that a child has an itchy bottom, some bleeding after using the bathroom or abdominal pain that prevents a child from using the bathroom. Erythema is a universal finding in both perianal disease and in vulvovaginitis. Additionally, vulvovaginal disease may have some of the same symptoms as urinary tract infections.
Young age and day care attendance are likely risk factors for infection. However, conclusive evidence of a specific mode of transmission remains lacking.
"There's more opportunity to pass infectious organisms among toddlers and young kids," Mogielnicki said. She also suggested that there may be differences in the chemical or physiologic characteristics of the skin in young children.
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Physicians at a small pediatric practice here noticed an increase in GAS perianal disease and vulvovaginitis starting in 1995. Most cases occurred in epidemiologically linked clusters. However, some appeared to be isolated infections. These cases seemed to mirror increased diagnosis of streptococcal pharyngitis in the community. Perianal and vulvovaginal disease appeared to share many characteristics.
Researchers examined clinical data on children with GAS perineal disease by analyzing perineal and pharyngeal streptococcal isolates. Children were included if they presented to the practice during 1997 with perineal symptoms and had physical findings consistent with published GAS infection reports and positive GAS cultures.
Researchers collected epidemiologic data on each case. Clinical data included symptoms, physical examination findings, presence or absence of clinical pharyngitis and recent GAS exposure. Researchers also collected laboratory GAS evidence in cases with throat symptoms or evidence of clinical pharyngitis.
Researchers identified 23 culture-confirmed cases of perianal and/or vulvovaginal GAS infection out of 4,530 routine office visits. Children ranged in age between 1 and 11 years old. All children attended day care, preschool or school. Thirteen children had only perianal infection; eight had vulvovaginal infection, and two children were infected at both sites. Fifty-seven percent of GAS disease occurred between March and May. Researchers did not find an increase in the background rate of streptococcal pharyngitis.
Of children with perianal disease, symptoms ranged from perianal pruritis or tenderness to abdominal pain and rectal bleeding. Girls with vulvovaginitis complained of symptoms that included dysuria, pruritis, tenderness and discharge.
Although researchers found perianal and/or vulvovaginal erythema on examination, <50% of children mentioned this. This inflammation was usually described as "beefy" red and was occasionally associated with edema. Researchers noted a papular rash on the buttocks or labia of some children, but this did not resemble impetigo. Three children had visible pus or discharge, and one girl with vulvovaginitis had a scarlatiniform rash over her lower abdomen. One boy developed guttate psoriasis.
Researchers found clinical pharyngitis in 11 children, although only five complained of current or recent sore throat. Nine of these children were tested for pharyngeal GAS, and eight were positive. Three out of 12 children without clinical pharyngitis or sore throat were tested for pharyngeal GAS, and all were positive. None was febrile in the office, but three had a recent history of at least a 102o fever. No child had petechiae.
Researchers suggested that the fact that 92% of pharyngeal tests were positive regardless of presence or absence of clinical pharyngitis symptoms may offer indirect support for the theory of autoinoculation or GI spread from an infected nasopharynx.
"In a high proportion of people who have perineal disease, you will find streptococcus in the throat," she said.
For more information:
- Mogielnicki NP, Schwartzman JD, Elliot JA. Perineal group A streptococcal disease in pediatric practice. Pediatrics. 2000;106(2):276-281.
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