PEDIATRICS Vol. 108 No. 3 September 2001, pp. 820-820

Perineal Group A Streptococcus

To the Editor.

There's an old joke: How do you tell the difference between a physician and an organic chemist in the men's room? The physician washes his hands after he's used the urinal; the organic chemist washes his hand before.

Mogielnicki et al¹ have documented many of the potentially significant factors associated with perineal Group A streptococcal disease and note that most cases occur in preschoolers 2 to 6 years old. They suggest potential roles for autoinoculation, airborne spread, and factors specific to particular strains.

The simplest explanation, however, may be that children 2 to 6 years old often have their bottoms wiped by their caregivers caregivers who may have streptococcal disease and who, like physicians, are good at washing their hands afterwards, but who are not washing their hands before.

Don Seidman, MD
Elmhurst Pediatrics of the DuPage Medical Group
Elmhurst, IL 60126

REFERENCE

1. Mogielnicki NP, Schwartzman JD, Elliott JA Perineal group A streptococcal disease in a pediatric practice. Pediatrics. 2000; 106:276-281 [Abstract/Free Full Text]

In Reply.

We welcome Dr Seidman's addition to the list of possible factors affecting perineal Group A streptococcal (GAS) infections in toddlers. Inoculation by parents or day care providers is certainly plausible.

The puzzle of perineal GAS etiology has acquired some new pieces since the 1997 data were collected for the paper noted above.¹ A recent decrease in case numbers suggests, in retrospect, that we experienced a 4-year epidemic of unusual GAS manifestation. The increase in perineal GAS disease in our practice was first noted anecdotally in 1995, continued to be a common diagnosis in 1996, was documented in our article in 1997, and continued (but with lesser numbers) in 1998. Since then, the diagnosis of perineal GAS in this practice has become a rare and sporadic event despite a high index of suspicion among clinicians.

This decline in frequency of diagnosis does not correlate with the pattern of GAS pharyngitis diagnosis in the community. Positive rapid antigen test numbers at our medical center and in this pediatric practice have remained relatively stable over the last several years. In contrast, positive GAS cultures from all sources other than throat have shown a decline that mirrors the decrease in perineal streptococcal disease.

We have discussed this issue with the author of an earlier article that described an outbreak of perianal disease among 31 children in a 9-month period in 1985-1986.² Dr Kokx reports that the frequency of diagnosis did not persist in that pediatric practice but that perineal disease continues to be encountered on a sporadic basis.

This change in frequency of diagnosis is most consistent with the hypothesis that specific GAS types have an affinity for body sites other than the pharynx, and that these strains may be present usually in low levels among the organisms that cause the yearly outbreaks of streptococcal pharyngitis. Alternatively, it is possible that the strains with an affinity for perineal skin (and wounds) sporadically undergo qualitative changes that affect attachment factors or other relevant characteristics. In the meantime, bottoms continue to be wiped and toddler comportment is less than optimal in terms of health risk, but it seems that we can relax our vigilance for this unusual manifestation of GAS disease.

Nancy P. Mogielnicki, PA, MPH
Joseph D. Schwartzman, MD
John A. Eliot, PhD
Dartmouth-Hitchcock Medical Center
Lebanon, NH 03756-0001

REFERENCES

1. Mogielnicki NP, Schwartzman JD, Elliott JA Perineal group A streptococcal disease in a pediatric practice. Pediatrics. 2000; 106:276-281
2. Kokx NP, Comstock JA, Facklam RR Streptococcal perianal disease in children. Pediatrics. 1987; 80:659-663 [Abstract/Free Full Text]