Washington Report on Health

When pus forms in a joint of an infant or young child, the physician must diagnose and treat quickly or the joint may be damaged beyond repair. The case study of a six week old girl with pneumococcal infection of the right hip illustrates the urgent problem of suppurative arthritis in the young. In another case appropriate therapy prevented damage from a possible hip infection in a three and one-half year old girl.     

Pneumococcal vaccine failure

Polyvalent pneumococcal polysaccharide vaccines are not 100 percent effective in preventing pneumococcal disease. In the case reported, pneumococcal meningitis and bacteremia developed about two years after the patient received the vaccine. When a patient presents with an illness that is consistent with pneumococcal infection, this etiology must be considered, regardless of the immunization history.     

Pneumococcal bacteremia as a marker for human immunodeficiency virus infection in patients without AIDS

We retrospectively reviewed medical records of all adult patients with blood cultures positive for Streptococcus pneumoniae to determine the number of HIV seropositive patients in whom S pneumoniae bacteremia was the presenting manifestation. We also compared the clinical presentation, laboratory data, and outcome of pneumococcal bacteremia in patients who were HIV seropositive with patients with no risk factors for HIV infection. All adult patients with blood cultures positive for S pneumoniae from January 1987 through April 1989 at two acute care general hospitals in northern California were identified by review of microbiology data. One hospital served veterans, the other the indigent of a suburban area. Six (15%) of 41 patients with pneumococcal bacteremia were HIV seropositive; five were not known to be HIV seropositive before the onset of bacteremia, and the sixth was asymptomatic with respect to HIV infection. No patient with AIDS had pneumococcal bacteremia. HIV seropositive patients were significantly younger, had significantly fewer underlying diseases, and had fewer complications of pneumococcal bacteremia than bacteremic patients with no risk factors for HIV infection. Patients with pneumococcal bacteremia should be evaluated for HIV infection, especially in the absence of other underlying diseases that predispose to pneumococcal bacteremia.     

PCR fingerprinting analysis for differentiation of Streptococcus pneumoniae reinfection versus relapse

Polymerase chain reaction fingerprint profiles of isolates obtained during an episode of pneumococcal pneumonia with bacteremia differed significantly from profiles of isolates obtained from the same patient during a subsequent episode of pneumococcal meningitis with bacteremia. Polymerase chain reaction fingerprinting provides a means of differentiating new infection from relapse, and may be a simple molecular tool for comparison of Streptococcus pneumoniae isolates.     

Occult pneumococcal bacteremia and empyema without preceding pulmonary parenchymal involvement

We have presented a case of pneumococcal empyema without evidence of pulmonary parenchymal infection. We postulate that the pleural space was hematogenously seeded from an unexplained pneumococcemia. This manifestation of pneumococcal infection is unusual, particularly since the patient was receiving adequate antibiotic therapy before the radiologic or clinical appearance of the empyema. This emphasizes the need for diagnostic thoracentesis when the clinical situation changes, even after appropriate antimicrobial therapy is begun.     

Bacteremic and leukopenic pneumococcal pneumonia: successful treatment with antibiotics, pulse steroid, and continuous hemodiafiltration

 We describe a case of bacteremic, leukopenic pneumococcal pneumonia with respiratory failure, accompanied by diabetic ketoacidosis and hypothermia. Pulmonary leukostasis may play a role in the pathogenesis of the acute respiratory distress syndrome (ARDS) in pneumococcal pneumonia. The patient recovered with mechanical ventilation, intravenous antibiotics, pulse-steroid therapy, and continuous hemodiafiltration (CHDF). In particular, administration of steroid and the use of CHDF may improve the status of pulmonary leukostasis in leukopenic pneumococcal infection. Received: October 22, 2001 / Accepted: March 14, 2002     

肝移植术后髋关节新型隐球菌感染1例并文献复习

目的报道1例肝移植术后髋关节新型隐球菌感染病例及相关文献复习,关注此病的发生及诊治。方法回顾性分析1例肝移植术后髋关节新型隐球菌感染病例,并以英文关键词“Cryptococcus”和“joint”或“arthritis”、中文关键词“隐球菌感染”和“关节”为检索词,检索PubMed数据库、中国知网数据库(CNKI)、万方数据库和维普数据库等国内外报道的病例,结合文献复习综合分析关节隐球菌感染的临床特点及诊疗方法。结果患者男性,39岁,因“左侧髋部肿痛2个月”入院,既往因肝硬化在外院行同种异体原位肝移植术,术后长期口服抗免疫排斥药物及激素治疗。髋关节经穿刺引流液培养确诊为新型隐球菌感染,严格抗真菌治疗后好转。文献共检索到9例关节隐球菌感染患者,其中男性5例,女性4例,年龄4~92岁;主要受累部位是膝关节4例,其次是髋关节3例。8例的临床症状仅表现为局部肿痛,1例合并发热;影像学多表现为关节周围溶骨性病变5例,其中2例合并局部软组织肿物形成。经及时手术干预和(或)抗真菌治疗后,7例患者治愈且随访未见复发,1例于出院3个月后不明原因死亡,1例确诊后要求转院失访。结论关节隐球菌感染的临床及影像学表现均缺乏特异性,极易与肿瘤、结核等疾病相混淆,当临床上怀疑本病时,应尽早行穿刺液或组织病原学检测,以免误诊和延误治疗造成严重后果。     

Pneumococcal endocarditis in adult patients. A report of five cases and review of the literature

A retrospective survey of patients with pneumococcal infective endocarditis at the University Hospital, Leiden, over a 10-year period (1976-1986) yielded five cases. Applying strict case definitions, four patients had definite and one patient possible pneumococcal endocarditis. The commonest presenting signs and symptoms were malaise, fever, and congestive heart failure. Predisposing conditions were previous splenectomy in one case and a valve prosthesis in another. The aortic valve was the most common site of infection. In four of the five patients the diagnosis of endocarditis was made during life. These patients were treated appropriately, i.e. with antibiotics to which S. pneumoniae is sensitive. In three patients, surgical intervention was performed in the acute phase because of progressive heart failure. Paravalvular abscesses were observed at surgery in all these cases. The four patients treated in our series recovered fully; the single fatal case constituted an unrecognized case of pneumococcal endocarditis. If recognized and treated appropriately (particularly with early selective surgery) endocarditis can be cured. In a statistical analysis of 36 patients with pneumococcal endocarditis reported during the past five years, we found a significantly higher occurrence and mortality in men than in women; no other clinical features were associated with a poor outcome of illness.     

A severe case of atypical hemolytic uremic syndrome associated with pneumococcal infection and T activation treated successfully with plasma exchange

BACKGROUND: A severe nondiarrheal form of hemolytic uremic syndrome in children is associated with pneumococcal infection (pHUS). Neuraminidase released by the pneumococci may cleave N‐acetylneuraminic acid residues on red blood cells (RBCs), leading to the exposure of the T cryptantigen and polyagglutinability of RBCs, a process known as T activation. Data suggest a pathogenic role of exposed T antigens on glomeruli interacting with naturally occurring anti‐T in the development of renal dysfunction in pHUS. By reducing the levels of anti‐T and neuraminidase, plasma exchange (PE) may have a role in the treatment of severe cases of pHUS. CASE REPORT: A previously healthy 2‐year‐old boy presented with acute renal failure, thrombocytopenia, microangiopathic hemolytic anemia, pneumococcal infection, and T activation of RBCs. A diagnosis of pHUS was made. Due to rapid clinical decline, daily single‐volume PE with 5 percent albumin replacement was initiated. Infusion of additional plasma was avoided by using only saline‐washed RBCs for transfusion. He made a full recovery after 13 PEs and remained well at follow‐up 7 months later. RESULTS: Polyagglutinability of RBCs was shown by mixing patient RBCs with five normal donor sera. The agglutination assays with a panel of lectins confirmed the specificity of exposed T antigen as the cause of polyagglutinability. CONCLUSION: The dramatic response seen in this patient suggests that PE utilizing albumin replacement may benefit patients with severe pHUS.     

Streptococcus pneumoniae serotype 6C presenting as recurrent prosthetic knee joint infection in a patient with a history of congenital asplenia and underlying autoimmune disease: a case report and literature review

This report describes a case of primary Streptococcus pneumoniae bacteremia with prosthetic joint infection caused by serotype 6C with recurrent infection in a patient with a history of congenital asplenia and underlying autoimmune disease. Isolates from the primary and recurrent infections were determined to be indistinguishable by pulsed-field gel electrophoresis. This study expands the conditions associated with recurrent invasive pneumococcal disease caused by serotype 6C.     

One-stage total hip arthroplasty for advanced hip tuberculosis combined with developmental dysplasia of the hip: A case report

BACKGROUNDA patient with advanced tuberculosis of the hip joint combined with Crowe type IV developmental dysplasia of the hip (DDH) and a drainage sinus is a rare condition. There are no previous reports of this condition, and it is a complex challenge for surgeons to develop a treatment scheme.CASE SUMMARYWe report a 73-year-old male patient with severe hip pain and drainage sinus of the left hip for one month. Approximately 40 years ago, a drainage sinus occurred at the lateral left hip was healed at the local hospital with anti-infectious therapy. After the sinus healed, gradual pain occurred in the left hip for 40 years. Approximately one month prior, hip pain was sharply aggravated, and a drainage sinus reoccurred in the left hip. The X-ray and computed tomography examinations showed destruction of the head and neck of the left femur, as well as an acetabular deformity. The results of Mycobacterium tuberculosis antibody and Xpert were positive. Therefore, the patient was diagnosed with advanced TH combined with Crowe type IV DDH. After 22 d of treatment with anti-tuberculosis chemotherapy, the sinus healed, and the patient underwent one-stage total hip arthroplasty (THA) surgery consisting of debridement, osteotomy, and joint replacement. After surgery, the patient received anti-tuberculosis chemotherapy drugs for nine months, with no recurrent infection. After one year of follow-up, the Harris score of the patient increased from 21 pre-THA to 86.CONCLUSIONAlthough drainage sinuses are a contraindication to one-stage THA, one-stage THA is still an effective and safe surgical method after the sinus heals.     

Pneumococcal vaccine

Streptococcus pneumoniae is a major cause of systemic infection and respiratory tract infection. All age groups may be affected, but the highest rates of pneumococcal disease occur among young children and elderly individuals. Now, two pneumococcal vaccines are available in Japan. The 23-valent pneumococcal polysaccharide vaccine(PPV23) is the vaccine to prevent invasive pneumococcal disease and pneumonia among adults. The 7-valent pneumococcal conjugate vaccine (PCV7) is the vaccine to prevent invasive pneumococcal disease and respiratory tract infection among young children. Unfortunately, so far, both of the vaccines have used as a voluntary vaccine in Japan. The widely use of PPV23 and PCV7 is expected for the prevention of pneumococcal disease in Japanese people.     

Pneumococcal sepsis and meningitis in adults with sickle cell disease

Patients with sickle cell disease are predisposed to infection caused by Streptococcus pneumoniae. However, there has been only one published case of bacteremic pneumococcal meningitis in an adult with sickle cell anemia. We report here the cases of six adults with sickle cell disease, pneumococcal sepsis, and meningitis. Five patients were male and one was female. Their ages ranged from 18 to 34 years (mean, 25.7 years). Five patients had the SS and one had the SC hemoglobin phenotype. Only one patient had received pneumococcal vaccine (14 valent). This vaccine did not protect against the pneumococcal serotype causing his infection. All patients had high fever (mean, 39.8 degrees C [103.7 degrees F]) on admission; five had generalized weakness and four had neck stiffness. Leukocyte counts were greater than 30,000/mm3 in all patients. Streptococcus pneumoniae was isolated from the blood and the cerebrospinal fluid in all patients. The cerebrospinal fluid showed pleocytosis in six patients, an elevated protein level in five, and hypoglycorrhachia in two. Complications included renal failure in four patients, disseminated intravascular coagulation in one, and seizures in another. Two patients died. Pneumococcal sepsis and meningitis are uncommon in adults with sickle cell disease, but they carry a high morbidity and mortality. Wider use of the new 23-valent polysaccharide vaccine in these patients is recommended.     

Recurrent bacterial meningitis by three different pathogens in an isolated asplenic child

Isolated congenital asplenia (ICA) is a rare condition at risk for overwhelming infection. When complicated by invasive infection, the mortality remains high, at greater than 60%. We describe a girl with ICA who developed recurrent meningitis by three different pathogens. The first, meningitis by Escherichia coli, occurred 4 days after premature birth. The other two pathogens were serotype 6B Streptococcus pneumoniae and Haemophilus influenzae type b (Hib), at 18 and 25 months of age, respectively. The patient was successfully treated with prompt antimicrobial therapy in all episodes. Serum anti-polyribosylribitol phosphate (PRP) and anti-6B-type pneumococcal antibodies were below the levels for protective activity after natural infections. Although anti-PRP antibody was significantly increased after Hib vaccination, two (6B and 19F) of seven serotype-specific pneumococcal antibodies were not elevated to protective levels after the second 7-valent pneumococcal conjugate vaccine (PCV7). We, therefore, added a third PCV7. To our knowledge, this is the first neonatal ICA patient with invasive infection and the first case of bacterial meningitis occurring three times. Our findings indicate that monitoring of immune responses after natural infections and vaccinations, and reevaluations of vaccine schedule, are important for ICA patients to prevent subsequent invasive infections.     

Prospective Comparison of Cefoxitin and Cefazolin in Infections Caused by Aerobic Bacteria

Intravenous cefazolin and cefoxitin were compared in a prospective randomized trial in infections where the suspected pathogen was expected to be susceptible to both antibiotics. In the cefazolin group (12 patients) the diagnosis was pneumonia in 4, including 2 with pneumococcal bacteremia, soft tissue infection in 5, Staphylococcus aureus bacteremia in 1, acute pyelonephritis in 1, and disseminated gonococcal infection in 1. In the cefoxitin group (10 patients) the diagnosis was pneumonia in 4, including 2 with pneumococcal bacteremia, soft tissue infection in 4, acute pyelonephritis in 1, and disseminated gonococcal infection in 1. In the cefazolin group receiving an evaluable course of therapy, a good clinical response was seen in 10 of 11 patients, and a bacteriological response was seen in 5 of 7. Cefazolin failed to eradicate S. aureus bacteremia in 1 patient and S. aureus in a skin ulcer of another patient. All 10 cefoxitin patients had good clinical and bacteriological responses, but in 1 patient S. aureus colonization of a postoperative wound recurred after discontinuation of the drug. Side effects in both groups included skin rash, phlebitis, and elevation of the serum alkaline phosphatase. Both cefoxitin and cefazolin appeared effective in infections caused by susceptible aerobic pathogens with the possible exception of S. aureus, although all 11 strains of S. aureus isolated in this study were susceptible in vitro to both antibiotics. Cefoxitin appeared to be equivalent to cefazolin in efficacy and occurrence of side effects.     

Statins protect against fulminant pneumococcal infection and cytolysin toxicity in a mouse model of sickle cell disease

Sickle cell disease (SCD) is characterized by intravascular hemolysis and inflammation coupled to a 400-fold greater incidence of invasive pneumococcal infection resulting in fulminant, lethal pneumococcal sepsis. Mechanistically, invasive infection is facilitated by a proinflammatory state that enhances receptor-mediated endocytosis of pneumococci into epithelial and endothelial cells. As statins reduce chronic inflammation, in addition to their serum cholesterol-lowering effects, we hypothesized that statin therapy might improve the outcome of pneumococcal infection in SCD. In this study, we tested this hypothesis in an experimental SCD mouse model and found that statin therapy prolonged survival following pneumococcal challenge. The protective effect resulted in part from decreased platelet-activating factor receptor expression on endothelia and epithelia, which led to reduced bacterial invasion. An additional protective effect resulted from inhibition of host cell lysis by pneumococcal cholesterol-dependent cytotoxins (CDCs), including pneumolysin. We conclude therefore that statins may be of prophylactic benefit against invasive pneumococcal disease in patients with SCD and, more broadly, in settings of bacterial pathogenesis driven by receptor-mediated endocytosis and the CDC class of toxins produced by Gram-positive invasive bacteria.     

Evaluation of anti-pneumococcal capsular antibodies as adjunctive therapy in experimental pneumococcal meningitis

OBJECTIVE: Bacteraemia concomitant with meningitis has been shown to greatly affect outcome. Consequently, the efficacy of serotype-specific anti-pneumococcal antiserum (APAS) was investigated in a rat model of pneumococcal meningitis. METHODS: Rats were infected with Streptococcus pneumoniae serotype 3. All rats received ceftriaxone starting 26 h post-infection. APAS was administered either at the time of infection or 26 h post-infection and effects were compared with rats treated with antibiotics only. RESULTS AND CONCLUSION: A significant clinical benefit was found when APAS was given at the time of infection whereas no effect was found when administered 26 h after infection. This work indicates that the clinical value of using APAS in pneumococcal meningitis may be limited.     

Effect of exchange transfusion with an oxygen-carrying resuscitation fluid on the efficacy of penicillin therapy of pneumococcal infection in rats.

The effects of exchange transfusion with Fluosol DA (FDA) or stroma-free hemoglobin on the outcome of pneumococcal infection in rats were determined. Rats were sham transfused or exchange transfused with 25 ml of FDA or stroma-free hemoglobin. They were then challenged intraperitoneally with Streptococcus pneumoniae type 3 and treated with penicillin for 120 h. Only 2 of 15 (13.3%) FDA-transfused rats were alive at 312 h compared with 11 of 15 (73.3%) concurrently studied sham-transfused control rats (P = 0.0016). Of 10 stroma-free hemoglobin-transfused rats and 10 concurrently studied sham-transfused control rats (P = 0.98), 8 from each group (80%) were alive at 312 h. Penicillin therapy only suppressed pneumococcal infection in FDA-transfused rats, and relapse occurred after therapy was stopped. This effect could not be attributed to interference with the bactericidal activity of penicillin against pneumococci, to an alteration in the pneumococcal burden before penicillin therapy or to an alteration of the leukocyte and polymorphonuclear leukocyte response by FDA. In contrast, pneumococcal infection in stroma-free hemoglobin-transfused rats was cured with penicillin therapy. These data showed that FDA altered the ability of rats to respond to pneumococcal infection.     

Concurrent primary pneumococcemia, disseminated intravascular coagulation, and sickle cell anemia

Fulminant pneumococcal infections are rare in teen-agers with sickle cell anemia. A 16-year-old black male with sickle cell anemia was treated as an outpatient for cryptogenic pain crisis, which delayed antibiotic therapy for primary pneumococcal septicemia for seven hours. This patient did not appear ill upon initial presentation but rapidly developed disseminated intravascular coagulation and died.     

Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996. Key aspects of these guidelines related to anti-infective prophylaxis, immunisation schedules and treatment of proven or suspected infection. A recent review of the guidelines was undertaken, with a view to updating the recommendations where necessary The guideline review process did not reveal any major change in patient groups considered at risk. Occupational exposure to certain pathogens may, however, be a new risk factor for some infections. The recommendations for anti-infective prophylaxis remain unchanged. New recommendations for vaccination include the use of meningococcal group C vaccine in previously non-immunised hyposplenic patients and a need to consider the use of seven-valent pneumococcal vaccine. Recommendations for treatment of suspected or proven infection have not been significantly amended, but a local protocol should take into account relevant resistance patterns. There is an identified urgent need for further research into the effectiveness of varying vaccination strategies in the hyposplenic patient, and audit of infective episodes in this patient group should continue long term. Key guidelines are summarised below, together with grades of recommendation.