Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

14 September 2021: Articles  Saudi Arabia

Viridans Group Streptococcus Meningitis in an Immunocompetent Child: A Case Report

Rare disease

Mohammed A. Almatrafi12ABDEF*, Alhanouf Almuflihi2BEF, Rawan Jarwann2EF, Shroq Alghraibi2EF, Enais Ashgar3E, Nouf Alsahaf3E, Abdullah J. Aburiziza12AE

DOI: 10.12659/AJCR.933089

Am J Case Rep 2021; 22:e933089



BACKGROUND: Viridans group streptococci (VGS) are commensal organisms in humans that are considered contaminants when isolated from culture specimens. However, VGS can be pathogenic when recovered multiple times from blood cultures or when in immunocompromised hosts. VGS are the leading cause of dental abscesses and infective endocarditis in children with underlying congenital heart diseases. They are not commonly involved in meningeal infections, but meningitis due to VGS can be fatal if not treated. The onset is usually preceded by an upper respiratory tract infection or in association with neurological surgical procedures.

CASE REPORT: Our patient was a 14-month-old girl with no significant past medical history who presented with fevers and irritability for 2 weeks. A full sepsis workup, including blood, urine, and cerebrospinal fluid (CSF) cultures, was obtained. Culture results were notable for the abundant growth of VGS in the CSF. However, brain imaging and echocardiogram were normal, with no evidence of brain abscesses or cardiac vegetations, respectively. The patient had shown marked clinical improvement after receiving 2 weeks of intravenous ceftriaxone, which was selected based on the VGS susceptibility profile.

CONCLUSIONS: Bacterial meningitis is one of the most burdensome infectious diseases worldwide, despite improvements in diagnostic methods, management, and national immunization programs. Clinicians should consider VGS in the differential diagnosis of potential infections that can cause meningitis.

Keywords: Irritable Mood, Meningitis, Bacterial, Viridans Streptococci, Endocarditis, Endocarditis, Bacterial, Female, Humans, Infant, Streptococcal Infections


Viridans group streptococci (VGS) are commensal organisms that reside in humans, specifically in the oral cavity, skin, respiratory system, and gastrointestinal system [1–3]. Although they have been known as organisms of low virulence and pathogenicity, serious life-threatening infections have been described [4]. VGS can cause several invasive infections, including native valve endocarditis, dental abscess, septicemia in neutropenic patients, brain abscess, and neonatal sepsis [5–10]. Meningitis secondary to VGS is rare, with VGS possibly only responsible for 0.3% to 5% of all cases of proven cultured meningitis [11,12]. Most reported cases were in adults, and less frequently in neonates [13,14]. Predisposing factors to such infections include history of trauma, neurosurgical procedures, penetrating trauma, and malignancy [13,15–18].

Case Report

A previously healthy 14-month-old girl was presented to clinical care with vomiting, irritability, and decreased activity. These symptoms were preceded by 2 weeks of documented fevers. Prior to hospital admission, she was seen at a local clinic and received 2 doses of ceftriaxone. Her birth and medical and surgical histories were unremarkable. She was not fully immunized at the time of presentation. There was no recent history of sick contacts, travel history, or animal exposure.

At presentation, the patient was extremely irritable. Her vital signs revealed a high-grade fever (39°C), tachycardia (pulse 135 beats/min), and tachypnea (32 breaths/min). She had a normal capillary refill time and perfusion in all extremities but looked pale. She had nuchal rigidity and stiffness. Her pupils were normal in size and reactive to light, bilaterally. The oral cavity examination revealed mild pharyngeal erythema without exudate, tonsillar enlargement, or obvious dental concerns. The physical examination was otherwise unremarkable.

Laboratory testing revealed leukocytosis (27 091 WBC/mm3) along with bandemia (17.3%). A lumbar puncture yielded cloudy cerebrospinal fluid (CSF) with pleocytosis (42 WBC/uL), 43% neutrophils, normal glucose level (61.0 mg/dL; serum glucose 80 mg/dL), elevated protein (207 mg/dL), and many gram-positive cocci in chains. After cultures had been collected from blood, urine, and CSF, intravenous vancomycin (20 mg/kg every 6 h) and ceftriaxone (100 mg/kg/day) were empirically started for suspected bacterial meningitis. A computed tomography scan and brain magnetic resonance imaging (MRI) were normal, with no evidence of brain abscesses. The CSF culture grew abundant colonies of bacteria identified as VGS using VITEK 2 GP ID CARD for identification, ST03 card for susceptibility test, and VITEK 2 Compact instrumentation (Biomerieux, France). The identification of VGS was further supported based on colony morphology, Gram stain, optochin resistance, bile solubility, no growth in 6.5% NaCl, and negative biochemical reaction for catalase (Figure 1). Antibiotic susceptibilities were determined according to the Clinical and Laboratory Standard Institute guidelines [19]. Her isolate was intermediate to ampicillin (minimum inhibitory concentration [MIC]=4 μg/mL) but sensitive to ceftriaxone (MIC ≤0.5 μg/mL); therefore, ceftriaxone was continued for the whole duration of therapy. Blood culture results were negative, and an echocardiogram showed no evidence of vegetations or valve pathology. Immune workup results were interpreted according to her age. The immunoglobulin levels (IgE=37.37 mg4L, IgA=29 mg/dL, IgG=6024mg/dL, and IgM=72 mg/dL) and lymphocyte subset comprehensive panel (absolute lymphocyte count=4731 cells4L, T lymphocytes [CD3+]=3311 cells/μL, T-helper cells [CD3+/CD4+]=1892 cells/μL, cytotoxic T cells [CD3+/CD8+]=946 cells/μL, B lymphocytes [CD19+]=1040 cells/μL, natural killer cells [CD16+4D56+]=283 cells/μL, CD4+/CD8+ ratio=2) were normal for her age. The patient was discharged home after she received 2 weeks of intravenous ceftriaxone. She had a normal hearing test upon discharge.


The principal clinical syndromes associated with VGS are bacteremia, subacute bacterial endocarditis, upper respiratory infection, and sepsis in patients with hematological malignancies [1,2,5,7]. VGS recovered from the CSF are often consistent with specimen contamination, rather than being true pathogens [3]. Nachamkin and Dalton reported that only 8 of 43 adult patients whose CSF cultures were positive for α- hemolytic streptococci other than Streptococcus pneumoniae were determined to be clinically significant and treated as meningitis [20]. Given the CSF parameter abnormalities, the number of organisms isolated, and the response to therapy, we believe that VGS was most likely the cause of meningitis in our patient’s case. The CSF glucose level can be normal in these infections [3].

The source of these infections for most cases is endogenous flora. Poor oral hygiene and dental procedures are known risk factors for VGS bacteremia and subsequent endocarditis [3]. In a single review of 55 adult cases of VGS meningitis, upper respiratory infection was found in 31% of patients, extracranial infection and endocarditis in 13%, and head trauma or neurosurgical procedures, including lumbar puncture, in 8%. In approximately 35% of these patients, a source of entry was not identified [11]. Our patient did not have a positive blood culture for VGS; however, we hypothesize transient bacteremia may have occurred secondary to upper respiratory infection prior to presentation to our hospital.

VGS have the tendency to develop brain abscesses and infective endocarditis [7,8]. Our patient did not have evidence of fluid collection on the brain MRI, and echocardiography showed no vegetation or valve disease. The basic immune workup, including immunoglobulin level and lymphocyte subset, did not reveal any abnormality, although VGS meningitis in the absence of cardiac involvement has been described in immuno-compromised patients [21,22]. VGS has not been shown to be associated with immunodeficiencies beyond profound neutropenia, cytarabine therapy, and mucositis [23].

VGS are generally susceptible to β-lactams, macrolides, tetracyclines, and aminoglycosides [24]. However, VGS have become increasingly resistant, which has created significant problems for clinicians in recent years. The percentage of resistance against penicillin and erythromycin in the medical literature ranges from 30% to 40% [21,22,25]. This resistance is believed to be due to the alteration of penicillin-binding protein [25]. The subtype isolated in our case was intermediate to penicillin, leading to the use of ceftriaxone for the entire 2 weeks of therapy.


VGS should be considered to be a true pathogen in patients with signs and symptoms of meningitis. Clinicians should be aware of the pathogenicity of this organism and the different invasive diseases that it can cause.


1.. Lyytikäinen O, Rautio M, Carlson P, Nosocomial bloodstream infections due to viridans streptococci in haematological and non-haematological patients: Species distribution and antimicrobial resistance: J Antimicrob Chemother, 2004; 53(4); 631-34

2.. Balkundi DR, Murray DL, Patterson MJ, Penicillin-resistant streptococcus mitis as a cause of septicemia with meningitis in febrile neutropenic children: J Pediatr Hematol Oncol, 1997; 19(1); 82-85

3.. Sinner SW TA, 2010; 44(1) :ed

4.. Guerrero-Del-Cueto F, Ibanes-Gutiérrez C, Velázquez-Acosta C, Microbiology and clinical characteristics of viridans group streptococci in patients with cancer: Braz J Infect Dis, 2018; 22(4); 323-27

5.. Sunwoo BY, Miller WT: Chest, 2014; 146(4); e121-e25

6.. Faden HS: Pediatr Infect Dise J, 2016; 35(9); 1047-48

7.. Sonneville R, Ruimy R, Benzonana N, An update on bacterial brain abscess in immunocompetent patients: Clin Microbiol Infect, 2017; 23(9); 614-20

8.. Issa E, Salloum T, Tokajian S: Front Microbiol, 2020; 11; 826

9.. Whiley RA, Fraser H, Hardie JM, Beighton D: J Clin Microbiol, 1990; 28(7); 1497-501

10.. Ammann RA, Laws HJ, Schrey D, Bloodstream infection in paediatric cancer centres – leukaemia and relapsed malignancies are independent risk factors: Eur J Pediatr, 2015; 174(5); 675-86

11.. Hoyne AL, Herzon H: Ann Intern Med, 1950; 33(4); 879-902

12.. Enting RH, de Gans J, Blankevoort JP, Spanjaard L, Meningitis due to viridans streptococci in adults: J Neurol, 1997; 244(7); 435-38

13.. Bignardi GE, Isaacs D: Rev Infect Dis, 1989; 11(1); 86-88

14.. Fikar CR, Levy J: Am J Dis Child (1960), 1979; 133(11); 1149-50

15.. Cabellos C, Viladrich PF, Corredoira J, Streptococcal meningitis in adult patients: Current epidemiology and clinical spectrum: Clin Infect Dis, 1999; 28(5); 1104-8

16.. Villevieille T, Vincenti-Rouquette MI, Petitjeans MF: Anesth Analg, 2000; 90(2); 500-1

17.. Bussink M, Gramke H-F, Van Kleef M, Marcus M, Bacterial meningitis ten days after spinal anesthesia: Reg Anesth Pain Med, 2005; 30(2); 210

18.. Møller K, Frederiksen EH, Wandall JH, Skinhøj P: Scand J Infect Dis, 1999; 31(4); 375-81

19.. , Performance Standards for Antimicrobial Susceptibility Testing: CLSI supplement M100, 2020, Wayne, PA, CLSI

20.. Nachamkin I, Dalton HP, The clinical significance of streptococcal species isolated from cerebrospinal fluid: Am J Clin Pathol, 1983; 79(2); 195-99

21.. Ergin A, Eser Ö K, Hasçelik G, Erythromycin and penicillin resistance mechanisms among viridans group streptococci isolated from blood cultures of adult patients with underlying diseases: New Microbiol, 2011; 34(2); 187-93

22.. Smith A, Jackson MS, Kennedy H, Antimicrobial susceptibility of viridans group streptococcal blood isolates to eight antimicrobial agents: Scand J Infect Dis, 2004; 36(4); 259-63

23.. Shenep JL, Viridans-group streptococcal infections in immunocompromised hosts: Int J Antimicrob Agents, 2000; 14(2); 129-35

24.. Pfaller MA, Jones RN, Marshall SA, Nosocomial streptococcal blood stream infections in the SCOPE Program: Species occurrence and antimicrobial resistance. The SCOPE Hospital Study Group: Diagn Microbiol Infect Dis, 1997; 29(4); 259-63

25.. Desai N, Steenbergen J, Katz DE, Antibiotic resistance of non-pneumococcal streptococci and its clinical impact: Antimicrob Drug Resist, 2016; 791-810

In Press

Case report  USA

Successful Surgical Extraction of an Embolized Iliac Vein Stent from the Right Heart: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.943620  


Case report  China (mainland)

A Forgotten Double-J Ureteric Stent as the Core of a Bladder Stone: A Case Report and Literature Review

Am J Case Rep In Press; DOI: 10.12659/AJCR.943781  

Case report  Japan

Simultaneous Acquisition of T790M Mutation and SCLC Transformation during Targeted Therapy in EGFR-Mutated ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.943466  

Case report  Brazil

Guillain-Barré Syndrome in a Patient Receiving Anti-Tumor Necrosis Factor for Crohn Disease: Coincidence or...

Am J Case Rep In Press; DOI: 10.12659/AJCR.943709  

Most Viewed Current Articles

07 Mar 2024 : Case report  USA

Neurocysticercosis Presenting as Migraine in the United States

DOI :10.12659/AJCR.943133

Am J Case Rep 2024; 25:e943133


10 Jan 2022 : Case report  Germany

A Report on the First 7 Sequential Patients Treated Within the C-Reactive Protein Apheresis in COVID (CACOV...

DOI :10.12659/AJCR.935263

Am J Case Rep 2022; 23:e935263

19 Jul 2022 : Case report  Saudi Arabia

Atlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19

DOI :10.12659/AJCR.936128

Am J Case Rep 2022; 23:e936128

23 Feb 2022 : Case report  USA

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923