From vesicles to ventricles: pediatric group a streptococcal meningitis post-varicella infection – a case report

BACKGROUND: Streptococcus pyogenes meningitis is a rare but potentially life-threatening infection in infancy. It can occur as a primary infection or as a complication of viral illnesses such as varicella, which can increase the risk of invasive bacterial disease. CASE PRESENTATION: We report a previously healthy 3-month-old boy who presented with fever, poor feeding, and a vesicular rash following varicella exposure. Despite outpatient acyclovir therapy, the patient developed dehydration and persistent fever. Cerebrospinal fluid (CSF) analysis revealed markedly elevated white blood cell counts, elevated protein, and low glucose. CSF Gram stain demonstrated gram-positive cocci in pairs, and CSF culture subsequently confirmed Streptococcus pyogenes (Group A Streptococcus) that was susceptible to penicillin, vancomycin, amoxicillin/clavulanic acid, ceftriaxone, teicoplanin and cefotaxime. The patient received broad-spectrum antibiotics, antivirals, and supportive care. Despite escalation to a tertiary pediatric intensive care unit (PICU), he developed progressive cerebral edema, refractory seizures, and loss of brainstem reflexes. Brain death was confirmed by clinical examination, apnea tests, and electroencephalography. On the final day of hospitalization, the patient developed endotracheal bleeding with cardiovascular collapse and could not be resuscitated. CONCLUSION: This case highlights the fulminant course of invasive S. pyogenes infection in infants, particularly following varicella. These findings underscore the need for early recognition, aggressive management, and potential role of varicella vaccination in preventing secondary bacterial complications.