Endocarditis due to group A beta-hemolytic Streptococcus in children with potentially lethal sequelae: 2 cases and review.

Bacterial endocarditis affecting the normal heart is rare in childhood. Here we describe 2 children who developed endocarditis due to group A b-hemolytic Streptococcus (GABHS) that required emergency cardiac surgery. These cases emphasize the importance of considering this diagnosis in children presenting with signs of embolism, for whom urgent intervention may avert catastrophe. Case 1. A 4-year-old boy presented with a 10-day history of fever and pain in his left foot. On examination he was feverish with purpuric lesions on his left thigh and dusky discoloration of his toes. The cardiovascular system was normal on the basis of clinical examination, but echocardiography revealed a large flailing vegetation attached to a mitral valve leaflet with severe associated regurgitation. He underwent urgent cardiac surgery to excise the vegetation and thrombus and repair the mitral valve. Two cultures of blood and a culture of a scraping from the left foot taken on admission yielded (untyped) GABHS. Culture of a throat swab taken earlier yielded no growth. Ischemia of the forefoot progressed to necrosis and amputation of 2 toes, leaving a residual deformity that required plastic and orthopedic surgery. He completed a 6-week course of antibiotics and has subsequently remained well. Case 2. A 33-month-old boy presented with hot, tender, painful swelling in his ankles and right knee 4 weeks after varicella. On examination he was pyrexial, tachycardic, and had splenomegaly. The remainder of the examination, including auscultation of the heart, was normal. He was treated with ibuprofen. Two days later his left leg suddenly became cold with impalpable pulses. A gallop rhythm and an ejection systolic murmur were heard over the precordium. Echocardiography showed perforation of the aortic valve with vegetation