Bartholin's Gland Abscesses Caused by Streptococcus pneumoniae in a Primigravida
A 25-year-old non-diabetic primigravida of 31 weeks gestation presented to the outpatient obstetrics and gynecology clinic with a painful lump on the right side of the vaginal opening and pain during the sexual intercourse of 1 week duration. She had a history of urinary tract infection 2 weeks before the presentation. On examination, there were a body temperature of 38°C and swollen and inflamed right labia majora. Pelvic examination revealed an enlarged, firm and tender 5 by 4 cm swelling of Bartholin's gland on the right side. Her laboratory work-up revealed low hemoglobin of 10.3 g%, white blood cell count of 6300/dl with differential count showing polymorphs of 73% and lymphocytes of 20%, eosinophil 1% and monocytes 6%. She has also reduced glucose-phosphate dehydrogenase (G6PD) activity. Her glucose tolerance test for pregnancy was 5.7 mmol/L (normal is <7.8 mmol/L). Here, hepatitis B and C and venereal disease research laboratory tests were negative. Her urine analysis showed pus cells 50-99 cell/HPF, with positive leukocyte esterase of 3+ and urine nitrite was negative; but her urine culture was sterile.\nComplete drainage of the abscess was done through a small surgical cut under local anesthesia in the out-patient clinic. Pus drained and sent immediately to the laboratory. Gram stain of pus revealed the presence of plenty of pus cells with Gram-positive cocci in pairs and short chains with its characteristic lancet shaped appearance and no Gram-negative diplococci were seen.\nCulture of the abscess material on blood and chocolate agar in 5% CO2 atmosphere revealed alpha hemolytic slightly mucoid colonies with “punched-out” center as the colonies age. No growth on MacConkey agar and anaerobic culture media was observed. Identification was done using catalase, bile solubility and optochin susceptibility tests. Catalase test was negative. Bile solubility test induced lysis of the organism using the tube method while the optochin susceptibility test showed a zone of inhibition of 16 mm with a 6 mm of 0.5 μg optochin disk. Antibiotic susceptibility testing done by disk diffusion method (using Mueller Hinton agar supplemented with 5% defibrinated sheep blood and the plate was incubated at 35°C in 5% CO2 atmosphere for 24 h) revealed resistance of the organism (no zone) to 1 μg oxacillin disk from oxoid (Unipath, Ontario, Canada). Hence, minimal inhibitory concentration (MIC) was done according to clinical and laboratory standards institute (2012)[] using Phoenix automated microbiology system (BD Diagnostics, Sparks, MD), which revealed penicillin MIC of 2 μg/ml that indicates susceptibility to parentral penicillin, amoxicillin, amoxicillin-clavulanic acid, cefepime, cefotaxime, ceftriaxone and meropenem.[] The organism was sensitive to amoxicillin (MIC 1 μg/ml), cefuroxime (MIC ≤ 0.5 μg/ml), cefotaxime (MIC ≤ 0.5 μg/ml), cefepime (MIC ≤ 0.5 μg/ml), meropenem (MIC 0.5 μg/ml), erythromycin (MIC ≤ 0.0625 μg/ml), tetracycline (MIC ≤ 0.5 μg/ml), levofloxacin (MIC ≤ 0.5 μg/ml) and vancomycin (MIC ≤ 0.5 μg/ml). The patient was treated with oral cefuroxime 500 mg twice-a-day for 1 week and repeat culture from the wound site on follow-up was found to be sterile.