Case of the Month - October 2010

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Moherndran Archary, Ashendri Pillay, Raziya Bobat
Paediatric Infectious Disease Unit, Department of Paediatrics and Child Health
University of KwaZulu Natal

In July 2010, a 6 year old HIV positive male child on HAART since June 2008 with immune restoration, presented to an emergency paediatric unit in Durban, with fever & headache of 1 week duration.

His immunisations were complete according to the South African vaccination schedule prior to 2009. He resides in KwaZulu Natal with his grandmother under poor social circumstances.
No prior history of head trauma or rhinorrhoea was noted
On examination he was pyrexial with a temperature of 38oC.
CNS examination revealed photophobia and neck stiffness with positive Brudzinski & Kernig signs. He had a normal level of consciousness.
A mildly inflamed left tympanic membrane was noted on ENT examination.

A primary diagnosis of meningitis was made & the relevant investigations carried out:
His full blood count revealed a WCC of 25 x 109/L, platelets 341 x 109/L, Hb 13 g/dL, a normal U&E and a mildly elevated globulin level of 43g/L on his liver function tests

HIV viral Load was undetectable & his CD4 was 308 cells/mL

CSF Biochemistry

Protein 2.60
Globulins +++
Chloride 112
Glucose 0.2


CSF MC&S

PMN 260
Lymphocytes 64
Erythrocytes 120


Gram positive cocci on CSF
Gram positive cocci on blood culture (figure 1)
Streptococcus pneumoniae identified on blood & CSF cultures
Both sensitive to Ceftriaxone

Figure 1. Blood culture showing Gram positive Streptococci



Further history revealed that it was his 5th admission for Streptococcus pneumonia meningitis.

Summary of Previous Admissions

2007/08	S. pneumoniae CSF cultures +ve Blood cultures -ve
2007 /09	S. pneumoniae CSF culture +ve           serotype 19 Blood cultures -ve
2009/03	S. pneumoniae CSF culture +ve Blood culture +ve        serotype 6A
2009/06	S. pneumoniae CSF culture +ve           serotype 23 Blood culture -ve

He had completed a full course of antibiotics with repeat CSF prior to discharge showing resolution of meningitis.


Figure A: X-ray sinuses showing right sinusitis


Figure B: CT Scan Mastoids confirming left mastoiditis

Assessment
1. HIV infection with immune restoration on HAART
2. Recurrent S. pneumoniae meningitis secondary to :
a. Chronic Mastoiditis
b. Previous Head injury with intracranial communication
c. Secondary immunodeficiency related to HIV
d. Primary immunodeficiency syndrome

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