Skip to content
Publicly Available Published by De Gruyter July 4, 2017

An unusual presentation of group A streptococcus infection in a newborn: with acute mastoiditis with no obvious clinical manifestation

Peymaneh Alizadeh Taheri, Mohsen Jafari and Fouzieh Mehrazmai

Abstract

Acute mastoiditis (AM) is rarely seen in newborns. It is characterized by retroauricular pain, swelling, tenderness and protrusion of the auricle. This is the first report of the neonatal mastoiditis in a 17-day-old term neonate with no obvious clinical manifestation of mastoiditis and no associated malformation of the ears and mastoids. A computed tomography (CT) scan of the temporal bones revealed right mastoiditis without osteitis, destruction of the mastoid bone or abscess formation. Discharge culture revealed streptococcus A colonies sensitive to ampicillin, ceftriaxone, vancomycin and chloramphenicol. She was successfully treated with intravenous ampicillin and ceftizoxime. No complication or recurrence was reported.

Introduction

Acute mastoiditis (AM), an infection of the mastoid air cells in the temporal bone, is rarely seen in young infants [1], [2]. AM is known as an intracranial complication of acute otitis media (AOM). The main pathophysiology of AM includes spreading of the infection from the middle ear into the mastoid process, blocking the aditus ad antrum and inhibiting the middle ear drainage [3].

The disease typically manifests with retroauricular pain, swelling, tenderness, protrusion of the auricle and suppurated discharge; however, children may not demonstrate the typical signs and symptoms [4]. Therefore, atypical manifestations such as gastrointestinal symptoms (vomiting, diarrhea), dehydration, weight loss and irritability may also occur [2]. Although most cases of AM resolve with adequate treatment, acute mastoiditis may lead to severe complications such as intracranial and extracranial abscesses, meningitis and lateral sinus thrombophlebitis [1].

Although AM is relatively common in young children, it is very rare in the neonatal population, especially in otherwise healthy newborns [1], [2], [5], [6]. This paper reports a rare case of AM following AOM in a17-day-old term newborn caused by group A streptococcus.

To our knowledge, this is the first case report of the neonatal mastoiditis following otitis media with no congenital malformations of the ear and mastoid and no obvious clinical signs in the mastoid area.

Case report

A 17-day-old term female neonate who presented to the neonatal clinic of Bahrami Children Hospital with a 2-days’ history of irritability and right ear otorrhea was admitted to the neonatal ward. According to her past history, the purulent otorrhea started on the 15th day after birth. She was born as the 2nd child of a 28-year-old Iranian mother. She was vaginally delivered with a normal Apgar score and a birth weight of 3850 g. She was exclusively breast fed and had received the routine neonatal vaccines.

On examination, the infant was irritable but afebrile and in a generally good condition with normal vital signs. On admission, her weight was 4020 g. The ears were morphologically normal and there were no congenital malformations. There was no erythema, edema and warmness in the mastoid area. The lymph nodes were intact. On otoscopy, the right tympanic membrane was erythematous and perforated. A yellowish discharge was detected at the tympanic membrane and through the external canal of the right ear. No foreign body was detected.

The results of the laboratory tests were as follows: total leucocyte count (TLC) 15,900/mm3 with 48% neutrophils, 43% lymphocytes, 6% monocytes and 3% eosinophils. Hemoglobin (Hb) was 11.8 g/dL, platelet count 604 × 1000/mm3, C-reactive protein (CRP) 12 mg/L and erythrocyte sedimentation rate (ESR) 40 mm/h. Biochemical indices were normal.

A diagnosis of acute right otitis media was made and the patient received intravenous ampicillin 50 mg/kg/dose every 6 h and ceftizoxime 50 mg/kg/dose every 8 h. The culture of external canal secretion revealed streptococcus A colonies sensitive to ampicillin, ceftriaxone, vancomycin and chloramphenicol. After 72 h, the yellowish discharge subsided and the patient’s clinical manifestations improved; however, the ESR increased to 85 mm/h and the CRP raised to 50 mg/L despite a week of antibiotic therapy. In view of the increasing ESR and CRP, with no other etiologic source of infection, a bone scan was performed that showed increased uptake of radionuclei in the right mastoid area with no increased uptake of radionuclei in other bones (Figure 1).

Figure 1: 
Bone scan showing increased uptake of radionuclei in the right mastoid area with no increased uptake of radionuclei in other bones.

Figure 1:

Bone scan showing increased uptake of radionuclei in the right mastoid area with no increased uptake of radionuclei in other bones.

Temporal computed tomography (CT) scan revealed right mastoiditis without osteitis, destruction of the mastoid bone or abscess formation (Figure 2).

Figure 2: 
Temporal CT scan demonstrating right mastoiditis without osteitis, destruction of the mastoid bone or abscess formation.

Figure 2:

Temporal CT scan demonstrating right mastoiditis without osteitis, destruction of the mastoid bone or abscess formation.

After the 2nd week of intravenous antibiotic therapy, the ESR declined to 15 mm/h and the CRP to 3 mg/L. The infant was discharged on oral amoxicillin for another 7 days. The parents were asked to attend the neonatal outpatient clinic for a follow-up visit in a week after discharge. In outpatient follow-up, there were no complaints or signs of recurrent infection. There was no more discharge of the right ear and the right tympanic membrane was intact with no perforation. The clinical examination of the right mastoid area was normal. The ESR and CRP were in the normal range. The antibiotic therapy was stopped after a total duration of 3 weeks. The repeated ESR and CRP were also in the normal range after 2 weeks and 1 month of stopping antibiotic therapy.

Discussion

AM is most commonly seen in children aged 1–4 years but is rarely reported in infants and neonates [1], [2]. According to a retrospective review of records for all children aged 0–16 years treated for AM during 1993–2007, the youngest patient was a 2-month-old infant [7]. Here, we report a case of neonatal AM.

The pathology of AM is determined by the infants’ middle ear anatomy. As the mastoid process is contiguous to the middle ear cleft, the infection of the middle ear can potentially spread from the middle ear into the mastoid air cells via the aditus ad antrum [3]. The infection may progress either directly through the cortex or indirectly via the emissary vein of the mastoid, causing periostitis [1], [2]. Furthermore, the infection may also lead to the destruction of the bony structures, defined as acute mastoid osteitis [3].

Typically, the infants with AM demonstrate ear protrusion, post-auricular swelling, redness, tenderness and ear discharge [1], [6], [7]. The mean duration of symptoms prior to the presentation varies between 6.1 days in infants below 1 year to 9.3 days in children aged 2–7 years [7].

The clinical diagnosis of AM should be further confirmed by imaging tools such as the CT scan of the temporal bone, which is very sensitive in detecting mastoiditis, showing opacification of the mastoid cells, enhancement of areas of abscess formation and the elevation of periosteum of the mastoid process [4].

Based on the literature, the most common pathogen responsible for AM is Streptococcus pneumoniae; however, other bacteria such as Staphylococcus aureus and Pseudomonas aeruginosa, Moraxella catarrhalis and group A streptococcus have also been reported, depending on the culture sites [1], [2], [6].

The management of acute mastoiditis varies across different settings. According to a recent review, most cases of uncomplicated pediatric AM are managed by the administration of intravenous antimicrobial therapy and myringotomy [8]. In those with subperiosteal abscess and more advanced stages of the disease, abscess drainage, myringotomy and mastoidectomy are indicated [8].

According to our search in different databases, very few cases of AM in the neonatal period are reported. Parpounas et al. [5] reported a case of AM in a 28-day-old newborn with aural atresia. Our patient was a 17-day-old term newborn who had no congenital auricular anomalies.

This is the first report of the neonatal mastoiditis in a term newborn infant with no obvious clinical manifestation of mastoiditis and no associated malformation of the ears and mastoids. Except purulent otorrhea of the right ear, there was no visible clinical evidence of the mastoid involvement that is an unusual presentation of mastoiditis in all ages.

Acknowlegments

The authors wish to thank the nursing staff of Bahrami Children Hospital’s Neonatal ward for their help in patient’s management and also the Research Development Center of Bahrami Children Hospital for literature search and revising the article.

Author’s statement

  1. Conflict of interest: Authors state no conflict of interest.

Material and methods

  1. Informed consent: Informed consent has been obtained from all individuals included in this study.

  2. Ethical approval: The research related to human subject use has complied with all the relevant national regulations, and institutional policies, and is in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.

References

[1] Stenfeldt K, Enoksson F, Stalfors J, Hultcrantz M, Hermansson A, Groth A. Infants under the age of six months with acute mastoiditis. A descriptive study of 15 years in Sweden. Int J Pediatr Otorhinolaryngol. 2014;78:1119–22.10.1016/j.ijporl.2014.04.027Search in Google Scholar PubMed

[2] Niv A, Nash M, Solvik Y, Fliss DM, Kaplan D, Leibovitz E, et al. Acute mastoiditis in infancy: the “Soroka” experience: 1990–2000. Int J Pediatr Otorhinolaryngol. 2004;68:1435–9.10.1016/j.ijporl.2004.06.008Search in Google Scholar PubMed

[3] Bluestone CD, Klein JO. Definitions, terminology and classification. In: Bluestone CD, Klein JO, editors., editor(s). Otitis media in infants and children. Ontario: BC Decker, Inc., 2007:1–20.Search in Google Scholar

[4] Chien JH, Chen YS, Hung IF, Hsieh KS, Wu KS, Cheng MF. Mastoiditis diagnosed by clinical symptoms and imaging studies in children: disease spectrum and evolving diagnostic challenges. J Microbiol Immunol Infect. 2012;45:377–81.10.1016/j.jmii.2011.12.008Search in Google Scholar PubMed

[5] Parpounas K, Bouka K, Athanasopoulos J, Lamprou M, Helmis G, Vlastos IM. Acute mastoiditis in a newborn with aural atresia. Case Rep Otolaryngol. 2012;2012:459293.10.1155/2012/459293Search in Google Scholar PubMed PubMed Central

[6] Barnett ED, Klein JO. Bacterial infections of the respiratory tract. In: Wilson CB, Nizet V, Maldonado Y, Remington JS, Klein JO, editors., editor(s). Remington and Klein’s infectious diseases of the fetus and newborn infant. Philadelphia: Elsevier Saunders, 2016:275–9.Search in Google Scholar

[7] Groth A, Enoksson F, Hultcrantz M, Stalfors J, Stenfeldt K, Hermansson A. Acute mastoiditis in children aged 0–16 years: a national study of 678 cases in Sweden comparing different age groups. Int J Pediatr Otorhinolaryngol. 2012;76:1494–500.10.1016/j.ijporl.2012.07.002Search in Google Scholar PubMed

[8] Kordeluk S, Kraus M, Leibovitz E. Challenges in the management of acute mastoiditis in children. Curr Infect Dis Rep. 2015;17:26.10.1007/s11908-015-0479-4Search in Google Scholar PubMed

Published Online: 2017-07-04

©2017 Walter de Gruyter GmbH, Berlin/Boston

Scroll Up Arrow