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
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
CSF cultures +ve
Blood cultures -ve
|2007 /09||S. pneumoniae|
CSF culture +ve serotype 19
Blood cultures -ve
CSF culture +ve
Blood culture +ve serotype 6A
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
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:
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)
Para-meningeal foci of infection associated with recurrent meningitis
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
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.
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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