Streptococcus constellatus Lymphadenitis in Chronic Granulomatous Disease

We read with interest the article titled “Streptococcal infections in Patients with Chronic Granulomatous Disease” by Falcone et al in August issue of the journal. We would like to report a case of lymphadenitis and pneumonia in a 14 year-old boy with chronic granulomatous disease due to Streptococcus constellatus a member of the Streptococcus anginosus group. This 14 year-old patient presented to our clinic with history of an enlarging neck mass for one week and two days of mild nonproductive cough. He did not have any constitutional symptoms. His physical examination demonstrated a 2×4 cm non-fluctuant and non-tender mass in the left anterior cervical area. The ultrasound of neck revealed conglomerated nodes without any suppuration. His chest xray demonstrated a left upper lobe consolidation. He underwent biopsy of the lymph node and bronchial alveolar lavage washings. Tissue cultures revealed alpha hemolytic colonies after 72 h on sheep blood agar, with a distinctive butterscotch smell. The API 20 Strep system (bioMerieux, Inc. Hazelwood, MO) did not yield an acceptable identification score. Matrix-assisted laser desorption/ionization time-offlight mass spectrometry (MALDI-TOF MS) using a MALDI-TOF MicroFlex LT mass spectrometer (Bruker Daltonics, Billerica, MA) identified Streptococcus constellatus with high score (∼2.0). We did not test our isolate for production of hydrogen peroxide. Histology of the node revealed acute and chronic inflammation and bronchial alveolar lavage washings yielded no growth. The patient is being treated with high dose amoxicillin and his clinical symptoms have improved. Our case not only extends the observations of Falcone et al but also records lymphadenitis due to Streptococcus anginosus group which is uncommon and has not been previously reported to our knowledge in CGD patients. It is however unclear in the few published cases of S.viridans infections in CGD , if further speciation was attempted or not. Our case not only illustrates the rarity of lymphadenitis due to S.anginosus group but also underscores the importance of observing the cultures for longer than 72 h.