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Group A Streptococcal Vulvitis in Adult Women

Clinical Features and Association With Psoriasis

Liegeon, Anne-Laure MD1; Berville, Sophie MD2; Wendling-Héraud, Jeanne MD3; Moyal-Barracco, Micheline MD2

Journal of Lower Genital Tract Disease: October 2019 - Volume 23 - Issue 4 - p 287–289
doi: 10.1097/LGT.0000000000000492
Case Series
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Objectives Group A streptococcus (GAS) vulvitis is rare, mainly reported in association with vaginitis. We examined the clinical features of GAS vulvitis in adults, the presence of other infected sites, and its association with dermatological conditions.

Materials and Methods We retrospectively analyzed the medical files and photographs of adult patients with bacteriologically confirmed GAS vulvitis seen at 3 private clinics. Coexisting infected sites, associated dermatological conditions, and bacteriological results for the husbands of 3 patients were examined.

Results Nineteen patients (mean age = 52.2 [range = 23–83] years) with vulvar GAS infections were identified. The vulvar symptoms consisted of pain (11 cases), pruritus (9), burning (4), and discharge (10). The predominant physical feature was bilateral erythema, mainly located on the labia minora and the inner aspect of the labia majora. This erythema was associated with oozing (3), edema (6), or fissures (6). Seventeen patients had an associated vaginal infection, which was asymptomatic in 7 cases; anal infections were present in 9 cases. The following 10 patients had associated dermatological conditions: psoriasis (6), lichen sclerosus (2), Paget disease (1), or vitiligo (1). Two (one each from the throat and penis) of the 3 bacteriological specimens taken from the 3 husbands were GAS positive.

Conclusions In most adult women, GAS vulvitis is associated with a vaginal infection that may be asymptomatic. A bilateral, oozing, and edematous or fissured erythema involving the vulvar or anovulvar area is suggestive of GAS vulvitis. The association with psoriasis and the benefits of screening household members and sexual partners deserves further attention.

1Department of Dermatology, Centre Hospitalier de Valence, Valence, France

2Private Vulvar Clinic, Paris, France

3Hôpital Tarnier-Cochin, Paris, France

Reprint requests to: Micheline Moyal-Barracco, MD, 4 rue Léon Delhomme, 75015 Paris, France. E-mail: micheline@barracco.net

The authors have declared they have no conflicts of interest.

This study was approved by Valence Hospital Ethical Committee.

Group A streptococci (GAS) are the most common infectious causes of vulvovaginitis in prepubertal girls.1,2 However, in adult women, GAS are isolated in only 0.5% to 4.9% of patients with vaginal discharges and in 0% to 0.3% of asymptomatic women.3,4 Although the usual vulvar symptoms of GAS vulvovaginitis are itch and pain, data regarding their physical features are lacking or are limited to “erythema” or “vulvitis” associated with a vaginal discharge.1–3 This study identified the clinical features and coexisting infected sites of adult women with vulvar GAS infections; it also investigated the association of GAS vulvitis with dermatological vulvar conditions.

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METHODS

The local ethics committee (Valence Hospital, France) approved this study.

We retrospectively analyzed the medical files and photographs of patients, seen at 3 clinics specializing in adult vulvar disease in Paris, France, with bacteriologically confirmed vulvar GAS infections. The analyzed data included each patient's age, symptoms, signs (based on descriptions and photographs), associations with other sites of bacteriologically confirmed GAS infections, and associated vulvar or extravulvar dermatological conditions. Bacteriological investigations were conducted on the husbands of 3 patients.

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RESULTS

Between 2006 and 2017, 19 patients (mean age = 52.2 years; median age = 50 years; range = 28–83 years) were diagnosed with vulvar GAS infections; 11 patients were menopausal and none were pregnant or breastfeeding. Photographs were available for 15 patients. The reported symptoms were pain (11 cases), pruritus (9), burning (4), and vaginal discharge (10). The physical features of 14 patients included bilateral erythema, mainly located on the labia minora and inner labia majora (see Figure 1). Oozing (3 cases), edema (6), and fissures (6) were also present; no systemic symptoms or signs were reported. The sites of infection concerned the vulva only (1), the vulva and the anus (1), the vulva and the vagina (9), as well as the vulva, vagina, and anus (8). All the vulvar specimens were positive. All the 16 vaginal specimens taken from the 19 patients with GAS vulvitis were positive for GAS. Ten of these 16 patients reported an abnormal discharge. Three patients did not have a vaginal specimen (heavy discharge in one and no discharge in the two others). Five specimens taken from the anal margin of 9 patients with a coexisting anitis were GAS positive. For 5 patients, no anal specimen was taken and no clinical information was available neither from the clinical files nor from the photos. The GAS-infected sites were not associated with other bacteriological or yeast infections. Ten patients had associated dermatological vulvar conditions: psoriasis (6), vulvar lichen sclerosus (2), anovulvar Paget disease (1), and vitiligo (1). In one case, vulvar psoriasis was diagnosed before the GAS vulvitis diagnosis. Psoriasis diagnoses were made concurrently with the GAS vulvitis diagnoses in 5 patients (see Figure 2) and were based on a positive vulvar biopsy (1), persistence of a well demarcated vulvar erythema after a bacteriologically confirmed cure of the GAS infection (1), or the presence of other psoriasis manifestations in 3 patients: psoriasis arthritis (1), scalp lesions (2), and family history of psoriasis (2). Two patients had moderate extravulvar atopic dermatitis.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

For 3 patients, household member investigations were performed. One husband demonstrated negative anal and throat swabs. One patient had 2 children who underwent antibiotic treatment for pharyngitis before the patient's first symptoms; her asymptomatic husband demonstrated GAS-positive penile specimens. The third patient's asymptomatic husband had a GAS-positive throat swab.

Patients were treated with β-lactam antibiotics (16), pristinamycin (2), or quinolone (1) for 7 to 15 days (see Table 1). Fourteen patients had a complete regression of symptoms (pain, pruritus) and coexisting signs (erythema, fissures, edema, oozing, discharge). Five patients had a recurrence within 1 to 2 weeks after completion of the treatment. No recurrence was reported after a second line of antibiotics (see Table 1).

TABLE 1

TABLE 1

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DISCUSSION

In this study, the main symptoms of vulvar GAS infections were pain and pruritus, consistent with the published literature,5–7 and the main signs were bilateral erythema, oozing, edema, and fissures. In all but 2 cases, GAS were also found in the vagina, regardless of whether they caused symptoms. The perianal area was infected in almost half of the patients, and an association with psoriasis was found in almost one third of the patients.

Eleven of our 19 patients were postmenopausal. Previous studies have indicated that postmenopausal estrogen deficiency is frequently associated with the absence of protective lactobacilli4,5 and may, thus, be a risk factor for GAS vulvovaginitis.

In all but one case, GAS vulvitis was associated with another infected site, typically the vagina (17/19 cases). However, vaginal discharge, the most common vaginal symptom1,2,6 in girls and adult women, was reported by only 10 of our 17 patients with GAS-positive vaginal specimens. The relatively low rate of reported vaginal discharge may be explained by asymptomatic GAS carriage or by underreporting due to the absence of systematic questions about vaginal discharge.

The main physical sign of GAS vulvitis was bilateral erythema of the labia minora and inner labia majora. Edema (see Figures 1, 2) was present in 6 patients, also reported by Verkaeren et al.7 Erythema, fissures, and edema have also been described in childhood perianal GAS infections.1,2,8 In adults, these signs may initially be interpreted as candidiasis, psoriasis, or contact dermatitis. Oozing has not been previously reported as a sign of GAS vulvitis or anitis and might be a more specific sign of GAS vulvitis.

Almost half of our 19 patients with GAS vulvitis had an associated dermatological condition, most commonly psoriasis (6 cases). In 5 of those cases, the psoriasis was only recognized at the time of the GAS vulvitis diagnoses. The association of guttate psoriasis with GAS pharyngitis, vulvovaginitis, or perineal infections is well documented9,10; the association of perianal or vulvar GAS infections, with psoriasis at the infection sites, has not been previously reported. We hypothesize that this association is not just a coincidence. Group A streptococci might have triggered infection site psoriatic lesions via immune reactions leading to T-cell stimulation and cytokine activation.10 Alternatively, GAS infections may have induced isomorphic responses, similar to those after trauma (Koebner phenomenon). Preexistent vulvar psoriasis might have also facilitated concurrent GAS infections.

The epidemiology of vulvovaginal GAS infections is poorly understood. In this study, GAS were found in the throats of two of the patients' husbands (and on the penis of one), suggesting the possibility of sexual transmission. Verkaeren et al7 suggested oral sex as a mode of transmission. Two cases of asymptomatic rectal carriage have been reported in the husbands of patients and interpreted to be the source of recurrent GAS vulvovaginitis.11 Group A streptococcal vulvovaginitis in adult women may also result from transmission from a patient's child, if the child has pharyngeal, perineal, or cutaneous infection or colonization.6,12 Thus, systematic investigations (pharynx and anus in both children and adults; penis, anus, vulva, vagina in adults) for sexual or nonsexual sources of transmission seem worthwhile, particularly in cases of recurrent vaginitis.11

This study describes the clinical features of an uncommon, underrecognized, vulvar infection. In this study, clinical signs were precisely analyzed from photographs available for 15 patients. The results suggest a relationship between GAS infections and psoriasis and emphasize the need for bacterial investigations of the patient's household members and sexual partners.

However, this study does not provide enough accurate information regarding the vaginal and anal clinical features coexisting with GAS vulvitis. The association with psoriasis also needs to be more fully investigated using systematic family histories; examinations of the whole skin, scalp, and nails; and vulvar re-examination of the patient after the cure of the GAS infection.

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CONCLUSIONS

Group A streptococcal vulvitis should be suspected in patients with painful, itchy, vulvar, or anovulvar bilateral erythema, particularly when associated with fissures, edema, or oozing. In most cases, a coexisting vaginal infection or colonization is identified. An association with dermatological conditions, such as psoriasis, does not seem coincidental; it may result from the GAS infection or from a superinfection from a vaginal GAS source. Bacteriological investigations of household members and sexual partners are worthwhile as antibiotic treatment of these GAS carriers might prevent recurrence of the infection.

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REFERENCES

1. Dei M, Di Maggio F, Di Paolo G, et al. Vulvovaginitis in childhood. Best Pract Res Clin Obstet Gynaecol 2010;24:129–37.
2. Clegg HW, Giftos PM, Anderson WE, et al. Clinical perineal streptococcal infection in children: epidemiologic features, low symptomatic recurrence rate after treatment, and risk factors for recurrence. J Pediatr 2015;167:687–93.
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8. Echeverría Fernández M, López-Menchero Oliva JC, Marañón Pardillo R, et al. Isolation of group A beta-hemolytic Streptococcus in children with perianal dermatitis [in Spanish]. An Pediatr (Barc) 2006;64:153–7.
9. Hernandez M, Simms-Cendan J, Zendell K. Guttate psoriasis following streptococcal vulvovaginitis in a five-year-old girl. J Pediatr Adolesc Gynecol 2015;28:e127–9.
10. Ferran M, Galvan AB, Rincon C, et al. Streptococcus induces circulating CLA(+) memory T-cell-dependant epidermal cell activation in psoriasis. J Invest Dermatol 2013;133:999–1007.
11. Sobel JD, Funaro D, Kaplan EL. Recurrent group A streptococcal vulvovaginitis in adult women: family epidemiology. Clin Infect Dis 2007;44:e43–5.
12. Hansen MT, Sanchez VT, Eyster K, et al. Streptococcus pyogenes pharyngeal colonization resulting in recurrent, prepubertal vulvovaginitis. J Pediatr Adolesc Gynecol 2007;20:315–7.
Keywords:

vulvovaginitis; vulvitis; Group A streptococcus; vulva; vagina; psoriasis

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