Meningite bacteriana: uma revisão / Bacterial meningitis: a review

A meningite bacteriana é uma inflamação das leptomeninges que envolvem o Sistema Nervoso Central. Essa patologia, que possui diversos agentes etiológicos, apresenta-se na forma de síndrome, com quadro clínico grave. Entre as principais bactérias que causam a meningite, estão a Neisseria meningitis e Streptococcus pneumoniae. A transmissão ocorre através das vias aéreas por meio de gotículas, sendo a corrente sanguínea a principal rota para as bactérias chegarem à barreira hematoencefálica e, a partir dessa, até as meninges. Atualmente existem vários métodos de diagnóstico precisos, onde a cultura de líquido cefalorraquidiano (LCR) é o método padrão ouro. Ademais, a melhora na qualidade do tratamento com beta-lactâmicos e a maior possibilidade de prevenção, devido à elevação do número e da eficácia de vacinas, vem contribuindo para redução dos casos da doença e de sua gravidade. Porém, apesar desses avanços, ainda há um elevado número de mortalidades e sequelas causadas por essa síndrome.

Bacterial meningitis is an inflammation of the leptomeninges that surround the Central Nervous System. This pathology, which has several etiological agents, is presented as a syndrome with a severe clinical scenario. The main bacteria causing meningitis include Neisseria meningitis and Streptococcus pneumoniae. It can be transmitted by droplets through the airways, with the bacteria using the bloodstream as the main route to reach the blood-brain barrier, and from there to the meninges. There are currently several accurate diagnostic methods, with CSF culture being the gold standard. In addition, the improvement in the quality of beta-lactam treatment and the greater possibility of prevention due to the increased number and effectiveness of vaccines have contributed to reducing the number of cases and severity of the disease. Nevertheless, despite these advances, this syndrome still presents a high number of mortalities and sequelae.

Pediatric bacterial meningitis and meningococcal disease profile in a Brazilian General Hospital

Abstract Objective To evaluate the clinical and epidemiological profile of bacterial meningitis and meningococcal disease in pediatric patients admitted to a Brazilian Secondary Public Hospital. Methods A descriptive observational study was conducted. Microbiologically proven bacterial meningitis or meningococcal disease diagnosed from 2008 to 2018 were included. Results A total of 90 patients were diagnosed with proven bacterial meningitis. There were 64 confirmed cases of meningococcal disease. The prevalence was higher in boys (n=38), median age 30 months (1-185). The main clinical manifestations were: meningococcal meningitis (n=27), meningococcemia without meningitis (n=14), association of meningococcemia with meningitis (n=13), and fever without a known source in infants (n=7).Admissions to intensive care unit were necessary for 45 patients. Three deaths were notified. Serogroup C was the most prevalent (n=32) followed by serogroup B (n=12).Pneumococcal meningitis was identified in 21 cases; out of the total, 10 were younger than two years. The identified serotypes were: 18C, 6B, 15A, 28, 7F, 12F, 15C, 19A and 14. Pneumococcal conjugate 10-valent vaccine covered four of the nine identified serotypes.Haemophilus influenzae meningitis serotype IIa was identified in three patients, median age 4 months (4-7). All of them needed intensive care. No deaths were notified. Conclusion Morbidity and mortality rates from bacterial meningitis and meningococcal disease remain high, requiring hospitalization and leading to sequelae. Our study observed a reduced incidence of bacterial disease over the last decade, possibly reflecting the impact of vaccination.

Frecuencia de Streptococcus pneumoniae aislados de enfermedad invasiva en Paraguay, serotipos y perfil de sensibilidad (2010-2018) / Frequency of Streptococcus pneumoniae isolated from invasive disease in Paraguay, serotypes and sensitivity profile (2010-2018)

Streptococcus pneumoniae sigue siendo una de las causas más importantes de morbilidad y mortalidad en niños y adultos alrededor del mundo. El objetivo del estudio fue describir la frecuencia de aislamiento de S. pneumoniae en enfermedad invasiva, distribución de serotipos y sensibilidad antimicrobiana en Paraguay (2010-2018). Se estudiaron 793 cepas de S. pneumoniae aisladas de pacientes de todas las edades con enfermedad invasiva en Paraguay, provenientes de los diferentes centros centinelas y colaboradores en el marco de la vigilancia de meningitis y neumonías, durante el periodo 2010-2018. La frecuencia general según diagnóstico resultó 74.9% de neumonías (n=594), 18.4% de meningitis (n=146) y 6.7% de sepsis (n=53). El serotipo 14 fue más frecuente con 174 aislamientos (22.0%), seguido del serotipo 19A con 84 aislamientos (10.6%), el serotipo 3 con 66 aislamientos (8.3%) y el 6A con 37 aislamientos (4.7%). En meningitis se registró una frecuencia general de resistencia a penicilina del 32,2% y de ceftriaxona del 1,4%. En los casos de no meningitis la resistencia a penicilina fue del 0,8% y ceftriaxona del 0,3%. Los resultados de serotipos y sensibilidad antimicrobiana proporcionarán información necesaria para la implementación de estrategias de prevención y tratamiento de la enfermedad neumocócica en nuestro país, por lo que es necesaria una vigilancia continua para evaluar la carga de enfermedad, los serotipos circulantes y el aumento de la resistencia a los antibióticos

Streptococcus pneumoniae remains one of the most important causes of morbidity and mortality in children and adults worldwide. The objective of the study was to describe the frequency of isolation of S. pneumoniae in invasive disease, serotype distribution and antimicrobial susceptibility in Paraguay (2010-2018). We studied 793 strains of S. pneumoniae isolated from patients of all ages with invasive disease in Paraguay, from different sentinel centers and collaborators in the framework of meningitis and pneumonia surveillance during the period 2010-2018. The general frequency according to diagnosis was 74.9% of pneumonia (n = 594), 18.4% of meningitis (n = 146) and 6.7% of sepsis (n = 53). Serotype 14 was more frequent with 174 isolates (22.0%), followed by serotype 19A with 84 isolates (10.6%), serotype 3 with 66 isolates (8.3%) and 6A with 37 isolates (4.70%). In meningitis, there was a general frequency of penicillin resistance of 32.2% and ceftriaxone of 1.4%. In cases of non-meningitis, penicillin resistance was 0.8% and ceftriaxone 0.3%. The results of serotypes and antimicrobial sensitivity will provide necessary information for the implementation of prevention strategies and treatment of pneumococcal disease in our country, therefore it is necessary to continue monitoring in order to assess the burden of the disease, circulating serotypes and increased antibiotic resistance

Meningitis recurrente por Streptococcus pneumoniae en una niña con un implante coclear y traumatismo craneoencefálico a pesar de haber recibido la vacuna neumocócica conjugada de 13 serotipos / Recurrent meningitis by Streptococcus pneumoniae in a girl with cochlear implant and head trauma despite 13-valent conjugated pneumococcal vaccine

La meningitis bacteriana recurrente es un fenómeno muy poco frecuente en los niños. Las fracturas de la base del cráneo y los implantes cocleares son factores predisponentes importantes, y el agente aislado con mayor frecuencia es el Streptococcus pneumoniae. La implementación de la vacuna neumocócica conjugada de 13 serotipos (VNC13) redujo la incidencia de enfermedades neumocócicas invasivas. La incidencia de enfermedades neumocócicas intercurrentes en pacientes vacunados suele estar relacionada con afecciones predisponentes preexistentes. En este artículo, presentamos un caso de meningitis neumocócica recurrente en una paciente con un implante coclear que sufrió un traumatismo craneoencefálico luego de haber recibido la vacunación completa con la VNC13. La paciente tuvo tres episodios de meningitis en el transcurso de un año. Se detectó la presencia de S. pneumoniae en el cultivo de líquido cefalorraquídeo (LCR) en el primer y tercer episodios, y mediante la prueba de reacción en cadena de la polimerasa (PCR, por su sigla en inglés) en el segundo episodio. Se realizó una intervención neuroquirúrgica luego del tercer episodio de meningitis, y la paciente no tuvo problemas de recurrencias durante los siguientes dos años. Hasta donde sabemos, en la bibliografía no se han descrito casos de meningitis de serotipo 1 por S. pneumoniae luego de la inmunización completa con PCV13.

Recurrent bacterial meningitis is a very rare phenomenon in children. Skull base fractures and cochlear implant are the important predisposing factors and, Streptococcus pneumoniae is the most frequently isolated agent. Implementation of 13-valent conjugated pneumococcal vaccine (PCV13) has reduced the occurence of invasive pneumococcal diseases. Vaccination breakthrough is typically related to underlying predisposing conditions. Herein, we reported recurrent pneumococcal meningitis in a patient with a cochlear implant who experienced a head trauma after being fully vaccinated with PCV13. The patient experienced three meningitis episodes within one year. S.pneumoniae was determined on CSF culture in the first and third episodes and detected by PCR at the second episode. Neurosurgical intervention was performed after the third meningitis episode, and the patient had no recurrence problems for the following two years. To our knowledge, breakthrough S.pneumoniae serotype 1 meningitis after full PCV13 immunization has not been reported elsewhere in the literature.

Meningitis crónica autoinmune secundaria a meningitis aguda por neumococo: caso clínico / Autoimmune chronic meningitis secondary to pneumococcal meningitis: report of one case

Pneumococcal meningitis produces several inflammatory disorders in susceptible subjects. A worsening of meningitis can occur on the fourth day of evolution in relation with the withdrawal of steroids. Other complications include the development of inflammatory signs in the post-acute stage of infection associated with disseminated vasculitis of the cerebral blood vessels and, even later, an autoimmune chronic meningitis. All these inflammatory complications are well controlled with the use of steroids. We report a 53-year-old woman with pneumococcal meningitis that had a good response to treatment with antibiotics and steroids. On the four day, after the steroids were discontinued, she complained of headache, became confused, and had an abnormal cerebrospinal fluid (CSF), report CT angiography showed signs of arteritis. She improved when the steroids were re-started. She was discharged in good condition but after slow tapering of the steroids over a four-month period she had a relapse of all her symptoms and had a gait disturbance. On readmission, she had an inflammatory CSF, there were no signs of infection and the cerebral MRI showed meningeal thickening with ventricular space enlargement. She improved again with steroids and she is now well on high-dose steroids but deteriorates each time the steroids are stopped. She experienced both acute and sub-acute inflammatory responses and finally developed a chronic meningitis responsive, and is dependent on steroids.

Meningitis por Streptococcus pneumoniae resistente a ceftriaxona: reporte de un caso / Ceftriaxone-resistant Streptococcus pneumoniae meningitis: case report

RESUMEN La meningitis infecciosa es una emergencia médica. Dentro del espectro de agentes infecciosos, el más importante es el Streptococcus pneumoniae, agente etiológico más frecuente de la meningitis bacteriana. El inicio de tratamiento antimicrobiano empírico es de gran importancia y considera a las cefalosporinas de tercera generación como la primera alternativa. Sin embargo, casos de resistencia a ceftriaxona han sido reportados en diversas partes del mundo, siendo un problema emergente, por lo que necesita una reconsideración de los esquemas antibióticos empíricos actuales. Presentamos el caso de un varón de 56 años que presenta meningitis aguda infecciosa por Streptococcus pneumoniae resistente a ceftriaxona, que respondió favorablemente al tratamiento empírico combinado con ceftriaxona y vancomicina y que durante su estadía hospitalaria se detectó la presencia de hipotiroidismo y megacisterna magna.

ABSTRACT Infectious meningitis is a medical emergency. Within the spectrum of infectious agents, the most important is Streptococcus pneumoniae, the most frequent etiological agent of bacterial meningitis. The initiation of empirical antimicrobial treatment bears great importance and considers third-generation cephalosporins as the first alternative. However, cases of ceftriaxone resistance have been reported in several regions of the world. This has become an emerging problem in need of reconsideration of the current empirical antibiotic treatment schemes. We present the case of a 56-year old man with acute infectious meningitis caused by ceftriaxone-resistant Streptococcus pneumoniae, who responded favorably to combined empirical treatment with ceftriaxone and vancomycin and to whom, during his hospital stay, the presence of hypothyroidism and mega cisterna magna was diagnosed.

Spatial analysis of pneumococcal meningitis in São Paulo in the pre- and post-immunization era

ABSTRACT OBJECTIVE To analyze the pneumococcal meningitis incidence rates in the State of São Paulo, Brazil, by age group, municipalities and micro-regions, as well as the spatial distribution of pneumococcal meningitis incidence rates among children under 5 years old in the pre- (2005-2009) and post-vaccination (2011-2013) periods and its associations with socioeconomic variables and vaccination coverage. METHODS The data source was the Brazilian Notifiable Diseases Information System. For the pre- and post-vaccination periods, thematic maps were built for pneumococcal meningitis incidence in under-5 children, by São Paulo state micro-regions, vaccination coverage and socioeconomic variables, using QGIS 2.6.1 software. Scan statistics performed by the SatScan 9.2 software were used to analyze spatial and spatiotemporal clusters in São Paulo municipalities and micro-regions. A Bayesian inference for latent Gaussian model with zero-inflated Poisson model through the integrated nested Laplace approximation was used in the spatial analysis to evaluate associations between pneumococcal meningitis incidence rates and socioeconomic variables of interest in São Paulo micro-regions. RESULTS From 2005 to 2013, 3,963 pneumococcal meningitis cases were reported in São Paulo. Under-5 children were the most affected in the whole period. In the post-vaccination period, pneumococcal meningitis incidence rates decreased among this population, particularly among infants (from 4.17/100,000 in 2005 to 2.54/100,000 in 2013). Two clusters were found in pre-vaccination - one of low risk for pneumococcal meningitis, in the northwest of the state (OR = 0.45, p = 0.0003); and another of high risk in the southeast (OR = 1.62, p = 0.0000). In the post-vaccination period, only a high-risk cluster remained, in the southeast (RR = 1.97, p = 0.0570). In Bayesian analysis, wealth was the only variable positively associated to pneumococcal meningitis (RR = 1.026, 95%CI 1.002-1.052). CONCLUSIONS Pneumococcal meningitis is probably underdiagnosed and underreported in São Paulo. Differentiated rates of pneumococcal meningitis diagnosis and reporting in each microregion, according to the São Paulo Index of Social Responsibility, might explain our results.

Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

Meningitis neumocócica en Cantabria (España) en la era de las vacunas conjugadas antineumocócicas (2001-2015) / Pneumococcal meningitis in Cantabria (Spain) in the pneumococcal conjugate vaccine era (2001-2015)

Objetivo. Analizar las características de la meningitis neumocócica en < 14 años tras la comercialización de vacunas antineumocócicas conjugadas en nuestra comunidad. Métodos. Estudio retrospectivo de los casos de meningitis neumocócica en el que se analizaron dos períodos: pre vacuna antineumocócica trecevalente (VNC13v) (2001-2010) y post-VNC13v (2010-2015). Se recogieron datos demográficos y clínicos de los pacientes y datos microbiológicos. Resultados. Se diagnosticaron 18 casos. La incidencia media pre-VNC13v fue de 2,3/100 000, y disminuyó a 0,5/100 000 tras la VNC13v. Los serotipos más frecuentemente identificados fueron 6A y 10A (pre-VNC13v); 6B y 15B (post-VNC13v, solo dos casos). Trece de dieciocho pacientes ingresaron en la Unidad de Cuidados Intensivos. Todos los casos fueron tratados con cefotaxima y recibieron dexametasona 14/18. Seis pacientes sobrevivieron con secuelas y uno falleció. Conclusión. Se observa un importante descenso en la incidencia de meningitis neumocócica desde la comercialización de la VNC13v, por lo que cabe esperar que tras su introducción sistemática se produzca un descenso aún mayor.

Objective. To analyze the characteristics of pneumococcal meningitis in children < 14 years old following the market introduction of pneumococcal conjugate vaccines in our community. Methods. Retrospective study of pneumococcal meningitis cases with a two-period analysis: pre-13-valent pneumococcal conjugate vaccine (PCV13) (2001-2010) and post-PCV13 (2010-2015). Patient demographic and clinical data, and microbiological data were collected. Results. Eighteen cases were diagnosed. The mean incidence in the pre-PCV13 period was 2.3/100 000, which reduced to 0.5/100 000 after the PCV13 introduction. The most commonly identified serotypes were 6A and 10A (pre-PCV13); 6B and 15B (post-PCV13, only 2 cases). Out of 18 patients, 13 were admitted to the intensive care unit. All cases were treated with cefotaxime, and 14/18 received dexamethasone. Six patients survived with sequelae, and 1 died. Conclusion. A major reduction has been observed in the incidence of pneumococcal meningitis since the introduction of the PCV13 to the market, so an even greater reduction is expected following its systematic introduction.

Características epidemiológicas, clínicas y bacteriológicas de meningitis neumocócica en pacientes pediátricos de Lima, Perú / Epidemiologic, clinical and bacteriologic characteristics of pneumococcal meningitis in pediatric patients from Lima, Peru

RESUMEN Objetivos. Describir las características clínicas, letalidad, susceptibilidad antibiótica y distribución de serotipos de meningitis neumocócica en pacientes pediátricos de Lima, Perú. Materiales y Métodos. Serie de casos de meningitis neumocócica en niños menores de 16 años. Los datos fueron obtenidos de dos estudios multicéntricos prospectivos, de vigilancia pasiva de enfermedad neumocócica invasiva realizados en Lima-Perú desde los años 2006 al 2008, y del 2009 al 2011. Resultados. Reportamos 44 episodios de meningitis neumocócica; 68,2% fueron en niños menores de 2 años. La tasa de letalidad fue 32,6; y 92,9% de los casos letales ocurrieron en niños menores de dos años (p<0,05). La desnutrición estuvo asociada a los casos letales (p<0,05). El 64,3% de los casos fatales murieron dentro de los 2 primeros días. El 41,9% de los cultivos con neumococo fueron resistentes a la penicilina, 23,3% mostró resistencia intermedia a ceftriaxona (ninguno mostró resistencia completa) y 9,3% mostró resistencia a cloranfenicol. Los serotipos más frecuentes fueron 6B, 14, 19F y 23F, los cuales constituyeron el 68,3% de todas las cepas; 84,1% de las cepas encontradas están incluidas en los serotipos de la vacuna 13 valente. Conclusiones. La meningitis neumocócica continúa siendo una enfermedad letal, especialmente en niños menores de 2 años. Dado que aproximadamente dos tercios de los casos letales fallecen en las primeras 48 h, es crítico un diagnóstico y tratamiento oportuno, así como asegurar el cumplimiento de la inmunización con la vacuna neumocócica.

ABSTRACT Objectives. To describe the clinical characteristics, lethality, antibiotic susceptibility, and serotype distribution of pneumococcal meningitis in pediatric patients in Lima, Peru. Materials and Methods. A case series of pneumococcal meningitis in children less than 16 years of age from two prospective, multicenter, passive surveillance studies of invasive pneumococcal diseases held in Lima-Peru from 2006 to 2008 and 2009 to 2011. Results. We report 44 pneumococcal meningitis episodes; 68.2% of them were in children less than 2 years old. The overall case fatality rate was 32.6%; 92.9% of fatal cases were in children less than 2 years of age (p<0.05). Malnutrition was associated with fatal cases (p<0.05). 64.3% of fatal cases died within the first two days. 41.9% of pneumococcal isolates were resistant to penicillin, 23.3% were intermediate resistant to ceftriaxone (none were highly resistant) and 9.3% were resistant to chloramphenicol. The most common serotypes were 6B, 14, 19F and 23F, which accounted for 68.3% of all strains; 84.1% of strains were PCV13 serotypes. Conclusions. Pneumococcal meningitis continues to be a lethal disease, especially in children less than 2 years of age. Since almost two third of lethal cases lead to death within the first 48 hours, prompt diagnosis and management is critical, as well as assurance of immunization with pneumococcal vaccine.

Comparison of PCR-based methods for the simultaneous detection of Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae in clinical samples

Abstract Background Several in-house PCR-based assays have been described for the detection of bacterial meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Haemophilus influenzae from clinical samples. PCR-based methods targeting different bacterial genes are frequently used by different laboratories worldwide, but no standard method has ever been established. The aim of our study was to compare different in-house and a commercial PCR-based tests for the detection of bacterial pathogens causing meningitis and invasive disease in humans. Methods A total of 110 isolates and 134 clinical samples (99 cerebrospinal fluid and 35 blood samples) collected from suspected cases of invasive disease were analyzed. Specific sets of primers frequently used for PCR-diagnosis of the three pathogens were used and compared with the results achieved using the multiplex approach described here. Several different gene targets were used for each microorganism, namely ctrA, crgA and nspA for N. meningitidis, ply for S. pneumoniae, P6 and bexA for H. influenzae. Results All used methods were fast, specific and sensitive, while some of the targets used for the in-house PCR assay detected lower concentrations of genomic DNA than the commercial method. An additional PCR reaction is described for the differentiation of capsulated and non-capsulated H. influenzae strains, the while commercial method only detects capsulated strains. Conclusions The in-house PCR methods here compared showed to be rapid, sensitive, highly specific, and cheaper than commercial methods. The in-house PCR methods could be easily adopted by public laboratories of developing countries for diagnostic purposes. The best results were achieved using primers targeting the genes nspA, ply, and P6 which were able to detect the lowest DNA concentrations for each specific target.

Enfermedad neumocócica invasiva en la era posvacunal: Reporte de un caso / Invasive pneumococcal disease in the post vaccine era: Case report

La enfermedad neumococica invasiva (ENI) es la presentación clínica más severa de la infección por Streptococcus pneumoniae. El Perú desde el año 2008 incluye a la vacuna antineumocócica en el calendario de vacunación nacional. Presentamos un caso de ENI en una niña de 10 años que acude por emergencia con signos meníngeos; además, dolor abdominal, infiltrado hilio basal derecho en la radiografía de tórax, presencia de líquido peritoneal y adenopatía peritoneal en las imágenes de apoyo diagnóstico. Se aísla en los cultivos de LCR y sangre el Streptococcus pneumoniae serotipo 11 A, cepa no vacunable, siendo sensible a ceftriaxona y vancomicina. Recomendamos la necesidad de conocer más sobre la presencia de serotipos de neumococo no vacunal en el contexto clínico-epidemiológico y su rol patogénico en población peruana...

Invasive pneumococcal disease (IPD) is the most severe clinical presentation of infection by Streptococcus pneumoniae. Peru since 2008 includes pneumococcal vaccine in the national immunization schedule. We report a case of a 10 year old girl who goes by emergency showing meningeal signs; in addition, abdominal pain, infiltrated right basal hilum on chest radiography, presence of peritoneal fluid and peritoneal adenopathy in diagnostic imaging support. It is isolated in blood and CSF cultures Streptococcus pneumoniae serotype 11A, no vaccine-strain, being sensitive to ceftriaxone and vancomycin. We recommend the need to know more about the presence of not vaccine pneumococcal serotypes in the clinical and epidemiological context and its pathogenic role in Peruvian population...

Clinical and bacteriological characteristics of invasive pneumococcal disease after pneumococcal 10-valent conjugate vaccine implementation in Salvador, Brazil

Abstract Invasive pneumococcal disease is a relevant public health problem in Brazil, especially among children and the elderly. In July/2010 a 10-valent pneumococcal conjugate vaccine was introduced to the immunization schedule of Brazilian children under two years of age. Between July/2010 and December/2013 we conducted a case-series study on invasive pneumococcal disease in Salvador, Brazil to describe the clinical and bacteriological profile of invasive pneumococcal disease cases during the post-implementation period. Eighty-two cases were eligible. Mean age was 31 years (interquartile range, 3–42); 17.1% and 30.5% were under 2 years and 5 years, respectively. Pneumococcal meningitis (n = 64, 78.1%), bacteraemic pneumococcal pneumonia (n = 12, 14.6%) and bacteraemia (n = 6, 7.3%) were the clinical syndromes identified. Thirty-three different serotypes were found. Of these, serotype 14 (n = 12, 14.6%) was the most common, followed by 23F (n = 10, 12.2%), 12F (n = 8, 9.8%), 18 C (n = 5, 6.1%) and 6B (n = 5, 6.1%). Investigations conducted in Salvador in the pre-vaccine period did not identify serotype 12F as one of the most prevalent serotypes. Increase of serotype 12F was observed in different regions of Brazil, in the post-vaccine period. Among children under two years of age, the target group for 10-valent pneumococcal conjugate vaccine, 11 (78.6%) of the 14 isolated strains of Streptococcus pneumoniae belonged to vaccine serotypes; at least 50% of these children were not vaccinated. The relatively recent implementation of 10-valent pneumococcal conjugate vaccine in Brazil reinforces the need to maintain an active surveillance of invasive pneumococcal disease cases, considering the possible increase of invasive pneumococcal disease cases related to non-vaccine serotypes and the changes on the clinical presentation of the disease.

Meningitis neumocóccica por serotipo 19 A, de curso fatal: ¿Un caso prevenible? / Fatal pneumococcal meningitis due to serotype 19 A: A preventable case?

Invasive pneumococcal disease (IPD) remains as an important cause of morbidity in the world and in our country, while in Chile the incidence has decreased after the incorporation of the 10 valent pneumococcal conju-gate vaccine, in the routine infant inmunization schedule (EPI). One of the expected effects of the program after vaccination with 10-valent pneumococcal vaccine is the likely replacement serotype phenomenon that means the presence of ENI caused by serotypes not included in the vaccine. In this context, we present the case of a child with pneumococcal meningitis caused by serotype 19 A of fatal course. The occurrence of ENI in a later stage of pneumococcal vaccine incorporation in Chile reinforces the importance of active surveillance, in order to know in detail the impact of vaccination, distribution of circulating serotypes and their correlation with the different clinical disease and their severity.

La enfermedad neumocóccica invasora (ENI) sigue siendo una causa importante de morbilidad en el mundo y en nuestro país, si bien en Chile la incidencia ha disminuido luego de la incorporación de la vacuna neumocóccica conjugada 10-valente al Programa Nacional de Inmunizaciones (PNI). Uno de los efectos esperables luego de la vacunación programática con la vacuna antineumocóccica 10-valente es el probable fenómeno de reemplazo, que corresponde a la presencia de ENI por serotipos no incluidos en la vacuna. En este contexto, se presenta el caso de un pre-escolar con meningitis neumocóccica causada por el serotipo 19 A, de curso fatal. La presencia de casos de ENI en una etapa posterior a la implementación de la vacuna anti-neumocóccica en el PNI de Chile, demuestra la importancia de realizar una vigilancia activa, con el objetivo de conocer en forma detallada el impacto de la vacunación, la distribución de los serotipos circulantes y su correlación con los diferentes cuadros clínicos y su evolución.

Caracterización de pacientes fallecidos por enfermedad neumocóccica invasiva en la poblacion infantil de Bogotá, Colombia / Characterization of patients who died of invasive pneumococcal disease in the child population of Bogota, Colombia

Introducción: El Streptococcus pneumoniae (S. pneumoniae), también denominado neumococo, es una de las principales bacterias asociadas a mortalidad en menores de 2 años, con una incidencia de morbimortalidad variable de acuerdo a la demografía y exposición a factores protectores o de riesgo. Objetivo: Caracterizar los pacientes fallecidos por enfermedad neumocóccica invasiva (ENI) entre el 2008-2014 en la población infantil de 8 instituciones de salud en Bogotá, Colombia. Pacientes y método: Estudio observacional descriptivo tipo serie de casos, en pacientes fallecidos por ENI, mayores de 28 días hasta los 18 años, en 8 instituciones de tercer nivel de atención en Bogotá, Colombia. Periodo del estudio del 1 de enero de 2008 al 15 de enero de 2014. Tamaño de la muestra: 239 pacientes. Resultados: Se revisaron 239 casos registrados de ENI, presentando una mortalidad del 7,5% (n = 18). La edad promedio de los pacientes que fallecieron fue de 43,7 meses, con un rango de edad entre 2 y 176 meses (14 años); el 66% de los casos era de sexo masculino. Se identificaron serotipos en 8 pacientes, encontrando: 6A, 6B, 10A, 14, 18C, 23B, 23F, 35B. La presentación clínica más frecuente de los casos de mortalidad fue meningitis con el 33% (6 casos), seguida por bacteriemia sin foco en el 28% (5 casos) y neumonía con el 27% (5 casos). Se presentaron situaciones clínicas combinadas como neumonía y meningitis en el 11% (2 casos). Dos de los pacientes tenían factores de riesgo para ENI claramente documentados (asplenia y enfermedad respiratoria crónica). Conclusiones: La mortalidad por ENI es especialmente alta en los menores de 2 años y en pacientes de sexo masculino, especialmente cuando presenta foco meníngeo (44%). La serotipificación no fue posible en todos los pacientes fallecidos, ya que no se envió la cepa aislada al Instituto Nacional de Salud. Se requiere una vigilancia continua y sistemática para evaluar el impacto de la vacunación y las posibles modificaciones en el patrón de presentación de la enfermedad.

Introduction: Streptococcus pneumoniae (S. pneumoniae), also known as pneumococcus, is one of the main bacteria associated with mortality in children under 2 years of age, with a morbidity and mortality incidence that varies according to demographics and exposure to risk, or protective factors. Objective: To describe the child mortality due to invasive pneumococcal disease (IPD) between 2008 -2014 (6 years), in 8 Medical Centres in Bogotá, Colombia. Patients and method: Descriptive observational case series of patients who died of IPD, aged 28 days to 18 years, in 8 tertiary care institutions in Bogota, Colombia. The study period was from 1 January 2008 to 15 January 2014. Sample size: 239 patients. Results: A total of 239 registered cases of IPD were reviewed, showing a mortality of 8% (n 18). The mean age of patients that died was 43.7 months, with an age range from 2 to 176 months (14 years), with 66% of the cases being male. Serotypes were identified in 8 patients, finding: 6A, 6B, 10A, 14, 18C, 23B, 23F, and 35B. The most common clinical presentation of the cases was meningitis with mortality of 33% (6 cases), followed by bacteraemia without focus in 28% (5 cases), and pneumonia with 27% (5 cases). Combined clinical situations were presented, such as pneumonia and meningitis in 11% (2 cases). Two of the patients had clearly documented risk factors for IPD (asplenia and chronic respiratory disease). Conclusions: IPD mortality is particularly high in children under 2 years in male patients, especially when presented with a meningeal focus (44%). Serotyping was not possible in all patients who died, since no strain isolated was sent to the National Institute of Health. Continuous and systematic vigilance is required to evaluate the impact of vaccination and possible changes in the pattern of presentation of disease.

Adrenal Insufficiency in 6-Year-Old Boy with Pneumococcal Meningitis

A 6-year-old boy with acute onset fever, mental change, and vomiting was admitted to the intensive care unit. He had neck stiffness and positive Kernig/Brudzinski sign. He showed neither skin pigmentation nor hirsutism. Brain magnetic resonance image showed diffuse sulcal T2 fluid attenuated inversion recovery hyperintensity in bilateral cerebral hemisphere. We started intravenous vancomycin and ceftriaxone. There was streptococcus pneumoniae in cerebrospinal fluid (CSF) culture. He showed no improvement of mental change and hemodynamic instability. His adrenocorticotropic hormone and cortisol level was 5.47 pg/mL and 15.08 µg/dL. We suspected adrenal insufficiency and prescribed intravenous hydrocortisone (50 mg/m2/day). Mental change and hemodynamic instability were improved after that. The CSF culture was negative 24 days after admission and he was discharged with oral hydrocortisone (10 mg/m2/day). In synacthen test (250 µg), basal and 60 minutes 17-OH-progesterone level was 3.84 ng/mL and 5.04 ng/ mL. We suspected non classic congenital adrenal hyperpalsia and planed further work up.

Clinical features of childhood purulent meningitis caused by Escherichia coli and Streptococcus pneumoniae: a comparative analysis / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the differences in clinical features of childhood purulent meningitis (PM) caused by Escherichia coli and Streptococcus pneumoniae, and to provide help for the selection of antibiotics for PM children with unknown etiology.</p><p><b>METHODS</b>A retrospective analysis was performed for the clinical data of children with PM caused by Escherichia coli (12 children) or Streptococcus pneumoniae (15 children).</p><p><b>RESULTS</b>Compared with the Streptococcus pneumoniae infection group, the Escherichia coli infection group had a significantly higher proportion of children with an age of onset of <3 months and a significantly higher incidence rate of convulsion, but significantly lower incidence rates of severe fever (>39°C) and disturbance of consciousness and a significantly lower proportion of children with an increased leukocyte count at diagnosis (>12×10(9)/L). The results of routine cerebrospinal fluid test and biochemical examinations showed no significant differences between the two groups. Escherichia coli and Streptococcus pneumoniae were resistant to cephalosporins and had a sensitivity to chloramphenicol more than 90%. Escherichia coli was fully sensitive to meropenem and Streptococcus pneumoniae was fully sensitive to vancomycin.</p><p><b>CONCLUSIONS</b>PM caused by Escherichia coli and Streptococcus pneumoniae has different clinical features. As for PM children with severe fever, disturbance of consciousness, and an increased leukocyte count, the probability of Streptococcus pneumoniae infection should be considered. For PM children with an age of onset of <3 months, medium- and low-grade fever, frequent convulsions, and a leukocyte count of <12×10(9)/L, the probability of Escherichia coli infection should be considered.</p>

Development of Spinal Epidural Abscess during Treatment of Pneumococcal Meningitis / 대한내과학회지

There have been a few reports of pneumococcal meningitis complicated by spinal epidural abscess. A 58-year-old female with Streptococcus pneumoniae meningitis underwent a recurrent pleocytosis without apparent clinical deterioration after appropriate antibiotic treatment. Subsequently, she developed a spinal epidural abscess. Spinal epidural abscess is a rare complication of pneumococcal meningitis, and subclinical deterioration of neutrophil-dominant pleocytosis may precede development of a spinal epidural abscess in individuals with bacterial meningitis.

Pacientes con infección del sistema nervioso central / Patients with central nervous system infection

INTRODUCCIÓN: las infecciones del sistema nervioso central constituyen un importante problema de salud. La aparición brusca de la sintomatología, el desenlace fatal en pocas horas o la permanencia de secuelas hace que estas enfermedades tengan un gran impacto social. OBJETIVO: caracterizar las infecciones del sistema nervioso central, su comportamiento y relación con la mortalidad. MÉTODOS: estudio observacional descriptivo y transversal en una muestra de 100 pacientes atendidos en el Hospital Militar Central "Dr. Carlos J. Finlay", entre enero de 2009 y diciembre de 2013. La información se recogió a través de las historias clínicas con diagnóstico al egreso de cualquier tipo de sepsis del sistema nervioso central y de los informes de necropsia. Se realizaron análisis estadísticos univariados y bivariados, y se hallaron las distribuciones de frecuencia absoluta y relativa. RESULTADOS: la edad media fue de 44,4 años. Predominó el sexo masculino en el grupo de ≤ 39 años (54,7 %); en el femenino prevaleció el grupo de 40-59 años (34,9 %). En los fallecidos predominó el grupo de 60-79 años (47,8 %) y en los egresados vivos los de ≤ 39 años (53,2 %). Los factores de riesgo se presentaron en el 64 % de los pacientes; las meningoencefalitis bacterianas y virales constituyeron el 77 %. El estudio citoquímico se indicó al 98 % de los pacientes y la positividad fue de 88,8 %. El agente causal más frecuente resultó el Streptococcus pneumoniae (33,3 %). El 33,7 % de los pacientes presentó complicaciones. La mortalidad fue del 23 %. CONCLUSIONES: la mortalidad por infección el sistema nervioso central fue elevada y resultó escaso el aislamiento de microorganismos. El hecho de que más de un tercio de los pacientes se hayan complicado, justifica la alta mortalidad presente en el estudio.

INTRODUCTION: central nervous system infections are a major health problem. The sudden onset of symptoms, the fatal outcome within a few hours or the remaining sequels makes these diseases have a major social impact. OBJECTIVE: characterize the central nervous system infections, their behavior and relationship to mortality at "Dr. Carlos J. Finlay" Hospital from January 2009 to December 2013. METHODS: an observational descriptive transversal study was carried out with 100 patients at "Dr. Carlos J. Finlay" Hospital from January 2009 to December 2013. Information was collected through medical records with diagnosis any type of sepsis central nervous system at discharge and from autopsy reports. Univariate and Bivariate statistical analyzes were conducted, and the distributions of absolute and relative frequencies were found. RESULTS: the average age was 44.4 years, there was male predominance in the group ≤ 39 years (54.7 %), but 40-59 years (34.9 %) prevailed in the female group. the deceased group, 60-79 years (47.8 %) majored and those living at discharge, the predominance was ≤ 39 years (53.2 %).Risk factors occurred in the 64 % of patients. Bacterial and viral meningencephalitis accounted for the 77 %. Citochemical testing was performed in 98 % of the patients and it proved positive in the 88, 8 %. The most frequent ethiological agent was Streptococcus pneumoniae(33, 3 %). Complications were present in 33, 7 % of the patients. The rate mortality reached 23 %. CONCLUSIONS: mortality due to CNS infection was high and the isolation of microorganisms was low. The fact that more than a third of patients have complicated substantiates the high mortality in the study.

Infección invasiva por Streptococcus pneumoniae: reporte de caso de un paciente con síndrome de Austrian / Invasive Streptococcus pneumoniae infection (Austrian syndrome): a case report

Descrito inicialmente en 1957 por Robert Austrian, el síndrome que lleva su nombre se define como la tríada de neumonía, endocarditis y meningitis secundarias a una infección invasiva por Streptococcus pneumoniae . Desde entonces, y debido a su infrecuencia, se han reportado muy pocos casos en la literatura científica. A continuación se presenta el caso de un paciente de 61 años de edad con un cuadro inicial de meningitis bacteriana por S. pneumoniae , acompañado de neumonía bacteriana e insuficiencia mitral grave asociada a cuatro vegetaciones sobre la cara auricular de la valva posterior, con ruptura y prolapso de su festón central posterior. Se aisló S. pneumoniae , serotipo 18C, en líquido cefalorraquídeo y en dos hemocultivos. El paciente recibió antibióticos de amplio espectro y fue sometido a reemplazo valvular temprano con un resultado clínico satisfactorio. El principal factor pronóstico de esta condición lo determina el daño valvular subsecuente, sobre todo en pacientes con compromiso de la válvula aórtica, por lo que es necesario identificar tempranamente la extensión del compromiso valvular y definir oportunamente el tratamiento quirúrgico y antibiótico del paciente. En casos menos frecuentes, en los que solo hay compromiso de la válvula mitral, la evolución clínica es menos aguda y, por lo general, el tratamiento antibiótico dirigido y las medidas de soporte avanzado suelen ser suficientes para su control.

Austrian syndrome is defined as the triad consisting of pneumonia, endocarditis and meningitis due to invasive Streptococcus pneumoniae infection. Few case reports have been reported since its first description in 1975 by Robert Austrian, mainly because it is rarely observed. Below we report the case of a 61 year-old male patient who presented with bacterial meningitis due S. pneumoniae followed by bacterial pneumonia and severe mitral regurgitation, associated with four vegetations on the atrial surface of the posterior mitral leaflet; in addition, there was rupture and prolapse of its middle scallop. The S. pneumoniae bacterium was isolated from cerebrospinal fluid and blood cultures. In consequence, the patient was given broad-spectrum antibiotic therapy and had an early valve replacement performed, obtaining a good clinical outcome. The key prognostic factor of the Austrian syndrome is determined by the damage of cardiac valves, particularly in patients with a compromised aortic valve; hence, it is necessary to identify the degree of valve injury and define surgical and antibiotic treatment on a timely fashion. However, in subacute, less frequent clinical cases where the mitral valve is the main valve compromised, usually a directed antibiotic therapy associated with advanced support measures are sufficient to control this infection.