Abstract
Introduction
Streptococcus pyogenes (SP) is responsible for pharyngitis and impetigo. Less frequently, it may cause balanitis in adults. We report a case of balanitis secondary to a mixed infection with SP and Candida albicans (CA) in a sexually active bisexual and diabetic patient.
Case
A 47-year-old bisexual man presented with acute balanitis. He reported having unprotected penetrative vaginal sex with his wife and unprotected oral sex with men. He had five casual male partners in the previous three months. His last exposure was three weeks prior to his presentation.
His medical history was notable for hypertension, obesity (body mass index = 28.2), hypertriglyceridaemia and diabetes mellitus (DM). However, he was non-compliant with medications prescribed by his treating physician. His last HbA1c, two months prior to his presentation, was 9.76 (normal < 6.3).
Seven days prior to his presentation, he developed redness over the dorsal aspect of his penis, along with a whitish secretion from the glans. He had no other complaints. He applied self-medicated topical econazole onto the affected area twice a day, for one week, without any notable improvement.
Physical examination revealed a circumcised penis with a ‘wet’ erythematous patch over its dorsal aspect, with a non-odorous, discreet white exudate from the patch itself (Figure 1). There were no micro-pustules, no meatitis, no ulcerations, no urethral discharge, no scrotal lesions and no inguinal lymphadenopathy. The patient was afebrile. There were no other relevant significant findings.
Erythema of the glans with a discreet fluid.
A culture of the whitish exudate was obtained and grew SP. A Sabouraud culture grew CA. Further fluid analysis by polymerase chain reaction (PCR) to rule out co-infection with Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Herpes simplex virus (HSV) was negative. NG-PCR and CT-PCR in urine and throat were equally negative. HIV, HBV, HCV and syphilis serologies were all negative. A diagnosis of balanitis secondary to a mixed infection with SP and CA was made. The patient was treated with fluconazole 150 mg/week for three weeks, along with amoxicillin 750 mg/day for seven days. Ten days later, the patient returned for follow up, with complete reported resolution of his symptoms, and no residual signs on physical examination.
The patient’s wife was examined with intent to treat. Vaginal and throat cultures for both SP and CA were obtained and were negative. Throat swabs from two of the patient’s five partners were also obtained for analysis. One partner, with whom the patient had unprotected oral sex three weeks prior to date, grew SP from his swab culture. We were unable to test the remaining three partners because they were out of the country.
Discussion
SP is a common cause of anal and genital infections in the paediatric population. 1 It occurs much less frequently in adults.2–4 SP balanitis is rarely reported in the literature.2–4 However, it is mentioned as a sexually transmitted infection (STI) in some references. 5 SP balanitis can easily be confused with NG balanitis. 3 We present this case to remind physicians treating STIs to consider SP as a potential cause of balanitis in their differential diagnosis. In addition, SP urethritis, regardless of how rarely it is reported, should be ruled out through an in-depth history of urinary symptoms. 3
In this case, SP was likely transmitted through oral sex from or to at least one confirmed partner. 5 Oral-genital transmission, occurring particularly in men who have sex with men, is rarely reported. 5 Treatment with amoxicillin is typically curative, except when SP is resistant.
It is of note that the patient has uncontrolled DM, in which case a genital CA infection or colonisation would not be unusual. Goswami et al. 6 reported significantly higher prevalence of Candida colonisation in diabetic patients with poor glycaemic control. Grigoriou et al. 7 isolated more CA from diabetic patients than from non-diabetics. There is considerable evidence for the role of acid proteinase as a virulence factor for CA, 8 and this might play a sentinel role in the pathogenesis of genital/vulvovaginal candidiasis. Nevertheless, the mechanism by which acid proteinase secretion causes pathology is not yet defined. 8 In our patient, CA might be a simple coloniser, or the aetiology of a full-blown candidiasis infection. Regardless, DM and CA colonisation/infection co-existence likely promoted the SP infection. We decided to treat with fluconazole. However, the mere presence of CA does not necessarily indicate a candidal infection and hence should not be treated unless there are specific signs of CA balanitis.
Treatment of candidiasis in a diabetic patient requires a topical and/or a systemic anti-fungal. 9 Lisboa et al. studied the risk factors for Candida balanitis in 478 men, and their frequency. They found that DM and age over 40 were two significant factors in 18% of their cases, versus other factors, such as same sex intercourse, and no circumcision, which were non-significant. 9
We report this case of SP balanitis in a diabetic, bisexual and sexually-active patient who had CA on his glans. As a final point, we emphasise the need to concomitantly test for all STIs in sexually-active patients.