Facial submandibular cellulitis associated with late-onset group B streptococcal infection

A complete history and systematic physical examination are important first steps in assessing any infant. In some instances these steps may provide immediate clues to a potentially life-threatening illness. This article presents the case of a former 26-week male infant, who presented on day of life 42, 32 weeks gestation corrected, with increased respiratory distress and an evolving lesion on the left lower cheek. The classic location and progressive erythema, warmth, induration, and tenderness in the submandibular region strongly suggested the diagnosis of group B streptococcal (GBS) cellulitis. Despite the presence of concurrent GBS septicemia, the infant had complete resolution of focal and systemic symptoms with 10 days of treatment. One month later, the infant developed pneumonia with respiratory failure, shock, culture-positive septicemia, and presumed meningitis and was again treated with broad-spectrum antibiotics. Diagnosis at that time was late-onset group B streptococcal infection. Serotypes were not available to aid in distinguishing between recurrent or persistent GBS versus a new occurrence of late-onset disease. A brief overview of late-onset GBS infections and their cutaneous manifestations, along with a step-by-step guide to physical examination, is provided. The differential diagnosis for facial cellulitis is reviewed with an emphasis on early recognition and treatment in light of the escalated risks for persistent or recurrent GBS infection in infants with GBS cellulitis.