Group C Streptococcal Sore Throat with Hepatitis – a Rare Association

Infection with beta-haemolytic streptococci is the most common bacterial cause of acute pharyngitis and tonsillitis in childhood. Hepatitis is also a known rare association with a few reported cases. Among the beta-haemolytic streptococci, group A is the commonest while other groups are also found to be rarely associated.1 A 10-year-old boy presented with fever and sore throat for 3 days and yellow coloration of skin and sclera for 2 days along with occasional vomiting. The boy was febrile with a temperature of up to 39°C. His urine was dark, and the stools were light coloured, were mildly jaundiced and a blister on the right knee joint. He developed a maculopapular rash, which started on the chest and rapidly spread all over the body. He had sore throat, typical strawberry tongue and a few enlarged cervical lymph nodes, abdomen was soft, with no organomegaly. Laboratory tests revealed elevated serum transaminases (Aspartate Aminotransferase (AST) 107 U/L, Alaninine Aminotransferase 202 U/L), and an elevated total serum bilirubin of 4.5 mg/dL. Alkaline phosphatase (236 U/L) and LActate Dehydrogenase (285 U/L) were in the normal range. His white blood cell count was 11 180/mm3 with 85% neutrophils; C Reactive Protein was 111 mg/dL. Hepatitis B Surface Antigen was negative and anti-HBs Immunoglobulin G (IgG) was positive, which confirmed his immunisation against Hepatitis B Virus. Serum assays for Immunoglobulin M and IgG antibodies against hepatitis viruses A and C as well as antibodies against cytomegalovirus and Epstein–Barr virus were negative. His urine and blood culture were sterile. Ultrasonogram of the hepatobiliary system was normal. The antistreptolysin-O titre was 156 IU/mL. Throat and skin swabs from the blister were found to be positive for a moderate growth of group C beta-haemolytic streptococcus. A course of cefuroxime was completed as per sensitivity. The patient recovered completely within 5 days and was discharged at which point his AST was 26 U/L, ALT 58 U/L, Gama Glutamil Transferase 45 U/L and bilirubin 1.5 mg/dL. Hepatitis during scarlet fever was first reviewed by MacMahon and Mallory2 in 1931. Since then, only a few reports on this association have been published. In a series reported from Canada, 15 of 24 (63%) patients with severe invasive Group A Beta Hemolytic Streptococcus infection had elevated liver transaminases.3 We did not consider liver biopsy in our case as the patient did not have a severe clinical course and recovered quickly. The pathogenesis of liver involvement under these circumstances is unclear. Direct toxic tissue injury as well as immunological reactions are the possible mechanisms suggested by authors.4 The frequency of hepatitis in children with group C beta-haemolytic streptococcal infection is unknown. Physicians managing invasive streptococcal infections should be aware of this uncommon but interesting association.

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