Case of the Month

October 2010

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


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

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


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

Question 1: What are the most common Streptococcus pneumoniae Serotypes causing invasive disease in children under 5 years in South Africa?

Answer to Q1

The 7 serotypes that cause 60% of all Invasive Pneumococcal Disease (IPD) in South Africa (SA) are included in the Pneumococcal Conjugate Vaccine (PCV7), which is part of the SA vaccination schedule.

In SA 75% of severe IPD occur in 5-6% of the childhood population who are HIV-infected.

The PCV is effective in decreasing the incidence of IPD and pneumonia as illustrated in the graphs below.

However efficacy of the vaccine in preventing invasive disease or pneumonia is lower in HIV-infected than HIV uninfected children.

Question 2: What serotypes are protected by Pneumococcal Conjugate Vaccine 7 (PCV7) and PCV13?

Answer to Q2

The PCV 7 contains polysaccharides of the capsular antigens of Streptococcus pneumonia Serotypes 4, 6B, 9V, 14, 18C, 19F, 23.

PCV 7 was included in the SA vaccination schedule in April 2009.

PCV 13 contains in addition to serotypes protected by PCV 7, serotypes 1,3,5, 6A, 7F, 19A.

PCV 13 (Prevnar 13, Wyeth Pharmacueticals Inc., a subsidiary of Pfizer Inc.) was licensed February 24, 2010 by the Food and Drug Administration (FDA) in the United States of America.

Question 3: What are the possible causes of recurrent meningitis in a child?

Answer to Q3

Recurrent meningitis is rare. It is defined as 2 or more episodes of meningitis separated by a period of complete resolution of signs, symptoms and laboratory findings.

Aetiology may be:

  • Predisposing Conditions
  • Infectious causes
  • Non-infectious causes

Pre-disposing conditions:

  1. A common predisposing condition is a communication between the subarachnoid space and base of skull secondary to head trauma or congenital defect.
  2. Mollaret Syndrome
  3. Familial Mediterranean Syndrome
  4. Sarcoidosis
  5. Systemic Lupus Erythematosus
  6. Primary Immunodeficiency syndrome
  7. Congenital Anomalies
    1. Anomalies of the anterior fossa
    2. Anomalies of Temporal fossa
    3. Spinal defects

Non-infectious causes:

Drug Induced

  1. Antibiotics,
  2. non steroidal anti-inflammatory,
  3. cytotoxic drugs,
  4. Intravenous Immune Globulin (IVIG)

Infectious causes:

Streptococcus pneumoniae is the most common cultured pathogen in bacterial causes, with no predominance of a particular serotype. (as compared to single episode meningitis)

Bacterial Infections (in decreasing order of incidence)

  1. S. Pneumoniae
  2. N. Meningitidis
  3. H. Influenzae
  4. E.coli
  5. Enterobacter spp

Para-meningeal foci of infection associated with recurrent meningitis

  1. Sinusitis
  2. Mastoiditis
  3. Brain Abscess
  4. Subdural empyema
  5. Infected Central Nervous System shunt

Question 4: What immunodeficiency syndromes are associated specifically with recurrent Streptococcus pneumoniae infections?

Answer to Q4

Immunodeficiency syndromes debilitate the host defence mechanisms against invading bacterial pathogens.

S. pneumoniae is a Gram positive, lancet-shaped polysaccharide encapsulated diplococcus. The capsular polysaccharide enhances its virulence by significantly impeding phagocytosis.

Children with the following immunodeficiency syndromes are at risk of recurrent S.pneumoniae infections

  • HIV
  • Congenital Immune Deficiency
    • some B or T lymphocyte deficiencies
    • Complement Deficiencies especially C1, C2, C3 & C4
    • Phagocyte disorders
  • Immunosuppressive therapy or radiation therapy for malignant neoplasms, leukaemias, lymphomas, Hodgkins disease


  1. Yogev R. Recurrent Meningitis. In Long: Principals and Practise of Paediatric Infectious Diseases, 3rd ed. 2008 Churchill Livingstone
  2. World Health Organisation. Initiative for Vaccine Research (IVR). Acute Respiratory Infections - Strepcoccus pneumonia
  3. Zar HJ, Madhi SA. Pneumococcal conjugate vaccine – advancing child health in South Africa. SA Journal of Child Health 2008; 2(3): 94-5
  4. Madhi SA. Introduction of the pneumococcal conjugate vaccine into the South African public immunisation programme: dawn of a new era? South African Journal Epidemiology & Infection 2008;23(4) 5-9
  5. Abramson JS & Overturf GD. Chapter 181. In: Nelson textbook of Paediatrics 18th Edition Eds; Kliegman RM, Behrman RE, Jenson HB, Stanton BF
Outcome of the case

The patient was discharged after being given a single dose of PCV7 as part of a catch-up regimen. Consideration was given to the use of either PCV13 or 23-valent Polysaccharide Pneumoncoccal vaccine due to the age of the child, however these vaccines were not available in the public sector. We recommend that all HIV positive children who have not benefited from pneumococcal vaccination be provided with a catch-up vaccination of PCV7.

Lesson learnt

The patient had recurrent episodes of vaccine preventable serotypes of S. pneumoniae, further emphasizing the need for catch-up vaccination of all HIV-positive children who have not received PCV7 as part of their immunization schedule.

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