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Letters to the Editor

Ultra-late-onset Meningitis Caused by Serotype IX Group B Streptococcus

Takahara, Tadamori MD; Matsubara, Kousaku MD, PhD†; Maihara, Toshiro MD, PhD; Yamagami, Yuji MD; Chang, Bin MD, PhD

Author Information
The Pediatric Infectious Disease Journal: July 2015 - Volume 34 - Issue 7 - p 801
doi: 10.1097/INF.0000000000000732
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To the Editors:

Streptococcus agalactiae [group B Streptococcus (GBS)] has been recognized as a leading cause of neonatal invasive diseases.1 Serotype is one of the most important factors that influence the pathogenesis of GBS infection.1 Nine antigenic variants (Ia, Ib, II to VIII) have been proposed, as well as serotype IX in 2007.2 Little is known about the clinical features, spectrum of infection and prognosis of this newly identified serotype infection. We present here details of the clinical course of an infant with ultra-late-onset serotype IX GBS infection.

A female baby weighing 3360 g was uneventfully born at 40 weeks gestation in 2013. Culture of a vaginorectal swab of her mother at 35 weeks gestation was negative. The patient had been well until 120 days of age when fever was noticed. Within 8 hours after the onset of fever, the patient became abruptly ill and was hospitalized. On admission, tachycardia, tachypnea, grunting and altered consciousness were noted. White blood cell count was 3780/μL, and C-reactive protein was 6.0 mg/dL. Cerebrospinal fluid examination showed pleocytosis (144 cells/μL), as well as low glucose (11 mg/dL) and high protein (290 mg/dL). The diagnosis was bacterial meningitis and compensated shock, so treatment with cefotaxime, meropenem, vancomycin, vasoactive agents and respiratory support was immediately started. After isolation of GBS from blood and cerebrospinal fluid, antibiotics were deescalated to ampicillin for 4 weeks. Despite these intensive treatments, disseminated intravascular coagulopathy, renal failure and diabetes insipidus occurred. Computed tomography of the head on the third hospital day showed cerebral edema and intracranial hemorrhage. The patient was managed with hypothermia to 34°C, plasma exchange and continuous vasopressin administration. The patient was discharged on the 54th hospital day with severe neurologic sequelae, including brain atrophy and porencephaly as well as nasogastric tube feeding. At 1 year 3 months, smile, eye pursuit or head control was not observed.

The isolate was serotyped as IX by the latex agglutination method with specific antisera (Statens Serum Institut, Copenhagen, Denmark). Multilocus sequencing type3 was 335, a one-allele variant of sequence type (ST)-19. The isolate was susceptible to β-lactams, erythromycin, clindamycin, ciprofloxacin and vancomycin.

Slotved et al2 first identified serotype IX from 2 newborns in Denmark and 6 adults worldwide, but the clinical information was limited to the isolated countries and years. To the best of our knowledge, there have been no reports of subsequent cases. A recent nationwide surveillance in Japan did not detect type IX invasive infections among 250 infants.4 We present for the first time clinical details of ultra-late-onset serotype IX GBS meningitis. Of note was a fulminant clinical course, resulting in severe sequelae.

ST-17 is known worldwide as highly virulent, linking with serotype III. However, ST-335 has been identified as a novel ST in 11.3% (17 of 150) of Japanese infants with invasive infections.5 Of the 17 strains, 16 and 1 were serotyped as III and VI, respectively.5 ST-335 is one of the most prevalent invasive strains in Japan.

Tadamori Takahara, MD

Department of Pediatrics, Hyogo Prefectural Tsukaguchi Hospital

Minami-tsukaguchi-cho, Amagasaki

Hyogo, Japan

Kousaku Matsubara, MD, PhD†

Department of Pediatrics, Nishi-Kobe Medical Center

Kojidai, Nishi-ku

Kobe, Japan

Toshiro Maihara, MD, PhD

Yuji Yamagami, MD

Department of Pediatrics, Hyogo Prefectural Tsukaguchi Hospital

Minami-tsukaguchi-cho, Amagasaki

Hyogo, Japan

Bin Chang, MD, PhD

Department of Bacteriology I, National Institute of Infectious Diseases

Toyama, Shinjuku-ku

Tokyo, Japan


1. Edmond KM, Kortsalioudaki C, Scott S, et al. Group B streptococcal disease in infants aged younger than 3 months: systematic review and meta-analysis. Lancet. 2012;379:547–556
2. Slotved HC, Kong F, Lambertsen L, et al. Serotype IX, a proposed new Streptococcus agalactiae serotype. J Clin Microbiol. 2007;45:2929–2936
3. Jones N, Bohnsack JF, Takahashi S, et al. Multilocus sequence typing system for group B streptococcus. J Clin Microbiol. 2003;41:2530–2536
4. Matsubara K, Hoshina K, Suzuki Y.. Early-onset and late-onset group B streptococcal disease in Japan: a nationwide surveillance study, 2004–2010. Int J Infect Dis. 2013;17:e379–e384
5. Morozumi M, Wajima T, Kuwata Y, et al. Associations between capsular serotype, multilocus sequence type, and macrolide resistance in Streptococcus agalactiae isolates from Japanese infants with invasive infections. Epidemiol Infect. 2014;142:812–819
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