Updated: 1/21/2019

Viridans Group Streptococci

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Snapshot
  • A 32-year-old man presents to his primary care physician for a wellness examination. He reports to currently feeling well; however, he notices severe discomfort and pain in his mouth. He denies any trauma to the area but endorses infrequently brushing his teeth. Medical history is significant for a ventricular septal defect that has not required repair. Physical examination is remarkable for dental caries leading to pulpitis. He is referred to a dentist for immediate dental care. Prior to tooth extraction, he will require prophylactic amoxicillin.
Introduction
  • Classification
    • gram-positive, optochin-resistant α-hemolytic cocci 
      • Streptococcus mitis
      • S. sanguis
      • S. mutans
  • Reservoir
    • normal flora of the oropharynx and live in close association with the teeth and gingiva
  • Microbiology
    • transmission
      • endogenous
    • reservoir
      • normal flora of oropharynx
    • molecular biology
      • biofilm mediates adherence to
        • heart valve
        • tooth enamel
      • forms vegetations
      • dextran mediated
        • dextran is an insoluble polysaccharide synthesized from glucose that allows the bacteria to adhere to surfaces 
        • requires pre-existing local deposition of fibrin for adherence
  • Pathogenesis
    • transient viridans streptococcal bacteremia
      • caused by eating, toothbrushing, flossing, or any other cause of minor trauma to the oropharynx
    • dental caries
      • localized dental hard tissue destruction caused by bacteria containing the ability to produce acid and grow in acidic environments such as S. mutans and S. mitis
    • periodontal disease
      • microorganisms in the subgingival dental plaque penetrate the gingival epithelium, leading to a host inflammatory response, damaging the periodontium
    • endocarditis
      • manipulation of the gingiva or periapical region of the oral mucosa (such as in dental procedures) can lead to bacteremic seeding of the heart valves and prosthetic devices such as in S. sanguinis
Presentation
  • Odontogenic infections (e.g., dental caries, gingivitis, and periodontitis)
    • symptoms
      • pain and discomfort
    • physical exam
      • pits and fissures on tooth surfaces and staining of teeth
      • discolored defect on tooth surfaces
      • gingival swelling
  • Endocarditis 
    • symptoms
      • chills
      • anorexia
      • weight loss
      • patients may have tooth pain or related symptoms
    • physical exam
      • fever
      • new heart murmur
Studies
  • α-hemolytic growth pattern
  • Optochin resistant
    • differentiates from S. pneumoniae, which is also α-hemolytic but optochin sensitive
Differential
  • Other causes of endocarditis
    • S. aureus
      • catalase-positive, coagulase-positive, gram-positive cocci
Treatment
  • Medical
    • antibiotic prophylaxis
      • indication
        • administered in patients undergoing dental procedures who are the highest risk of developing bacterial endocarditis
          • prosthetic heart valves
          • prior history of infective endocarditis
          • unrepaired cyanotic congenital heart disease
          • structurally abnormal valve in a transplanted heart
      • medications
        • amoxicillin
          • treatment of choice
Complications
  • Sepsis
  • Abscess
 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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