1. REVIEW ARTICLE
Lactational Amenorrhea as a Risk Factor for Group
A Streptococcal Vaginitis
Micelle C. Meltzer and Jane R. Schwebke
Department of Medicine, University of Alabama at Birmingham, Birmingham
We report a case of Streptococcus pyogenes, b-hemolytic Streptococcus, Lancefield group A vulvovaginitis in
an otherwise healthy adult female patient experiencing lactational amenorrhea. Group A streptococcal infection
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is the infective cause of vulvovaginitis in 21% of prepubescent girls, but it is an uncommon cause of vulvo-
vaginitis in adults. Group A streptococcal vulvovaginitis is frequently associated with households that have
had a recent outbreak of respiratory or dermal infection. The case described here appears to be unusual in
that it was sexually transmitted, and the lack of estrogen associated with anovualtion may have been a
predisposing factor for this unusual sexually transmitted disease.
The patient, a 32-year-old white woman who was 6 treated with 500 mg of amoxicillin 3 times per day for
months postpartum and was experiencing lactational 7 days. Follow-up via telephone confirmed that the
amenorrhea, presented to our clinic (University of Al- patient’s condition rapidly improved.
abama at Birmingham) during the winter with a pro- The patient had no recent history of dermal or re-
fuse, watery, yellow vaginal discharge. The discharge spiratory infection, but her 3-year-old son had been
was accompanied by moderate-to-severe vulvar pain treated for GAS pharyngitis 2 weeks before presenta-
and pruritus. The onset, which occurred 4 days before tion. The patient’s husband had been ill with an upper
presentation, was acute and occurred !24 h after having respiratory tract infection at the time of sexual contact.
unprotected vaginal sex with her husband. She denied After learning about his wife’s culture results, the pa-
having oral sex or digital penetration. A physical ex- tient’s husband (who was still ill) went to see his health
amination showed a yellow, watery discharge. The wet care practitioner. A nasopharyngeal culture sample was
mount preparation revealed numerous WBCs and was collected, and it was positive for GAS.
negative for Trichomonas vaginalis, clue cells, and yeast. Discussion. GAS vulvovaginitis in menarchal
Vaginal pH was not determined. Nucleic acid ampli- women is rare. In a study involving 3430 women and
fication test results were negative for gonorrhea and children with vulvovaginitis, the isolation rate in
women was just over 1% [1]. Historically, GAS was a
chlamydia. Gram staining revealed abundant seg-
common and often fatal cause of postpartum infection.
mented WBCs, gram-positive cocci in pairs and chains,
In the United Kingdom, from 1880 through 1930, there
and a notable absence of Lactobacillus-like gram-posi-
were 2000 deaths annually attributed to puerperal sepsis
tive rods (figure 1). A vaginal swab sample was sent to
[2]. GAS infection was spread between patients by doc-
the laboratory for culture. The patient’s culture grew
tors and midwives and was most common during the
abundant group A streptococci (GAS). The patient was
fall and winter months [2, 3]. Since the advent of an-
tisepsis, better hygiene, and antibiotics, there has been
Received 29 November 2007; accepted 24 December 2007; electronically
a sharp decrease in the incidence of puerperal infection
published 4 April 2008. caused by GAS. There are, however, anecdotal reports
Reprints or correspondence: Dr. Jane R. Schwebke, University of Alabama at
of current cases of GAS puerperal sepsis and an increase
Birmingham, 1530 3rd Ave. S ZRB 239, Birmingham, AL 35294-0007
(schwebke@uab.edu). in the rate of GAS isolated from high vaginal swab
Clinical Infectious Diseases 2008; 46:e112–5 samples obtained from menarchal women with vaginal
2008 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4610-00E3$15.00
discharge [2].
DOI: 10.1086/587748 In contrast, GAS vulvovaginitis is not uncommon in
e112 • CID 2008:46 (15 May) • Meltzer and Schwebke

2. Downloaded from cid.oxfordjournals.org at GlaxoSmithKline on January 27, 2011
Figure 1. A, Gram stain of vaginal fluid from a patient with group A streptococcal vaginitis. B, Gram stain of vaginal fluid with normal vaginal
flora.
young girls. Vulvovaginitis is the most common gynecological pruritus, and dyspareunia. There is often no odor, but if there
complaint among prepubescent girls. Its most frequent cause is, it is foul, not fishy like the odor associated with bacterial
is idiopathic (in 64% of cases), but it is sometimes associated vaginosis. Wet mount preparations reveal abundant WBCs,
with a specific bacterial pathogen [4]. GAS may be isolated in Gram staining often reveals gram-positive cocci in pairs and
as many as 59% of these cases [4]. GAS is most often isolated chains and few or no Lactobacillus species, and the pH is usually
from school-aged children with respiratory infections during quite elevated. Vaginal cultures often grow abundant GAS with
the fall and winter [3]. This seasonal preponderance is reflected few or no other organisms isolated [4, 8–13]. It should be noted
in the rate of GAS isolation from patients with vulvovaginitis, that the rate of vaginal carriage of GAS in healthy women and
as well [1]. Most cases of GAS vulvovaginitis in children have children ranges from 0% to slightly over 1% [8, 11]. Thus, if
had either a household or personal history of dermal or re- a patient is symptomatic and has culture results that are positive
spiratory infection due to GAS [4]. for GAS, this result should not be ignored, and the patient
GAS genital infections are not only associated with household should be treated with agents active against Streptococcus spe-
contact or autoinoculation with dermal and respiratory infec- cies. Typically, patients respond promptly to treatment. If im-
tions; they are also transmitted sexually. Fisk and Riley [5] properly diagnosed and treated, the condition will persist and
report a case in which a husband and wife both had GAS genital can sometimes spread rectally or even systemically.
infections after engaging in both oral and vaginal sex while the Anatomic, hygienic, and—perhaps most importantly—phys-
wife had pharyngitis. Wakatsuki [6] reports 47 cases of GAS iologic factors predispose prepubescent girls to bacterial vul-
balanoposthitis in which the route of infection was thought to vovaginitis. The anestrogenic vaginal epithelium in prepubes-
be sexual contact, especially through fellatio with commercial cent girls is thin and lacks cornification, and it is therefore
sex workers. Manalo et al. [7] describe a female patient with subject to irritation and infection. It also lacks glycogen de-
GAS tuboovarian abscess and peritonitis thought to be caused position and, consequently, lacks colonization with Lactobacil-
by engaging in receptive oral sex with a partner who had an lus species and vaginal acidification [4, 10, 12, 14]. It is known
upper respiratory tract GAS infection. Bray and Morgan [8] that healthy, Lactobacillus species–dominant, vaginal microflora
report 2 cases of GAS vulvovaginitis thought to be transmitted provide protection against the overgrowth of potentially path-
after vaginal intercourse only (i.e., oral sex was not believed to ogenic bacteria [15].
have occurred). Sobel et al. [9] report 2 cases of recurrent GAS Postmenopausal and postpartum women experience a sim-
vulvovaginitis in which the gastrointestinal tracts of the pa- ilar regression to the immature, anestrogenic vaginal environ-
tients’ husbands were colonized with GAS. ment found in prepubescent girls. The condition is called senile
The signs and symptoms of GAS vulvovaginitis are acute and vaginal atrophy in postmenopausal women and postpartum
typically more severe than those caused by other types of vag- vaginal atrophy in postpartum women. Both conditions are
initis. The most common findings are copious, yellow, sero- characterized by dyspareunia, vaginal stinging and tightness,
purulent vaginal discharge, edema, and marked vulvar and vag- dysuria, vaginal color change, an increase in parabasal cells, a
inal erythema. The patient usually complains of vulvar pain, decrease in Lactobacillus species, and an increase in vaginal pH
GAS Vaginitis • CID 2008:46 (15 May) • e113

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