Invasive group A streptococcal infections in children with varicella in Southern California

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ObjectiveTo describe demographic and clinical features of invasive group A streptococcal (GAS) infections in children with varicella in Southern California in early 1994.MethodsFrom hospitals of Los Angeles and Orange Counties, children with invasive GAS infections after varicella between January 1 and April 8, 1994, were identified by hospital infection control nurses. Medical records of patients were reviewed, and any available GAS isolate was further tested.ResultsTwenty-four cases were identified; 54% were male, 50% were Hispanic and the median age was 3 years (range, 0.5 to 8). Four cases died before hospitalization. The other 20 were hospitalized for a median of 10 days (range, 4 to 50): 14 presented with cellulitis (1 with concomitant epiglottitis), 2 with myositis/necrotizing fasciities, 2 with pneumonia and 2 with bacteremia without apparent source. Five had evidence of multiorgan involvement including two patients fulfilling criteria of streptococcal toxic shocklike syndrome. Of 19 patients with blood cultures, 10 (53%) had GAS bacteremia. Onset of GAS infection was suggested, as a median, on Day 4 of varicella, with fever, vomiting and localized swelling being commonly reported. The mean maximum temperature on the day of admission was 39.4°C (102.9°F). Four GAS isolates were M1T1 and one was M3T3. Five isolates produced streptococcal pyrogenic exotoxins A and B.ConclusionsInvasive GAS disease, including streptococcal toxic shock-like syndrome, is a serious complication of varicella. Physicians should be alert for the complication of GAS when fever and localized swelling or signs of cellulitis develop 3 days or more after the onset of varicella. Widespread use of varicella vaccine may decrease invasive GAS infections in this setting.

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