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.

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.

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.

Caracterização molecular de sorotipos não-vacinais de Streptococcus pneumoniae isolados de pacientes com meningite em Salvador, antes e após a implementação da vacina conjugada PCV-10 / Molecular characterization of non-vaccine serotypes of Streptococcus pneumoniae isolates from meningitis patients in Salvador, before and after implementation of the conjugate vaccine PCV-10

O advento das vacinas pneumocócicas conjugadas veio contribuir de forma decisiva para a redução da incidência dos casos de doença invasiva por S. pneumoniae em vários países do mundo. Em contrapartida, tem-se verificado um aumento de casos decorrentes de sorotipos não vacinais, que escapam da vacina e reduzem o seu efeito a partir da expansão de clones pré-existentes com consequente substituição de sorotipos e/ou do fenômeno de troca capsular (capsular switching). No Brasil, a vacina conjugada 10-valente (PCV10) foi introduzida no calendário nacional de imunização a partir de 2010. Este estudo teve como objetivo caracterizar através de técnicas fenotípicas e moleculares os sorotipos não-vacinais (SNVT) de S.pneumoniae, isolados de pacientes com meningite nos períodos anterior (janeiro/2008 - junho/2010) e posterior (julho/2010 - dezembro/2012) à implementação da vacina pneumocócica conjugada 10-valente (PCV10), na cidade de Salvador, Bahia. Os isolados de S. pneumoniae foram identificados através de métodos microbiológicos clássicos e a determinação do tipo capsular foi realizada através da técnica de Multiplex-PCR e/ou reação de Quellung. A sensibilidade a oito antimicrobianos foi realizada através da técnica de microdiluição em caldo e a caracterização genotípica por intermédio das técnicas de PFGE e MLST...

The licensure and subsequent widespread use of pneumococcal conjugate vaccines have contributed for the reduction in the overall incidence of invasive pneumococcal disease worldwide. However, the emergence of Streptococcus pneumoniae nonvaccine serotypes (SNVT), which escape from the vaccine by the expansion of pre-existing clones following serotype replacement and/or by capsular switching is a matter of concern. In 2010, Brazil introduced the 10-valent conjugate pneumococcal vaccine (PCV10) into its routine National Immunization Program. Our aim was to characterize the phenotypic and genotypic profile of S. pneumoniae non-vacine serotypes (SNVT) isolated from patients with meningitis before (January 2008 – June 2010) and after (July 2010 – December 2012) the introduction of PCV10 in Salvador, Bahia. The pneumococcal isolates were identified by classical microbiological methods and submitted to capsular deduction by multiplex-PCR and/or Quellung reaction. The antimicrobial susceptibility was performed the broth microdilution method. The genotypic profile was assessed by PFGE and MLST...

Austrian syndrome in the context of a fulminant pneumococcal native valve endocarditis

This is the case of a young male suffering from Austrian syndrome, which is the triad of endocarditis, meningitis, and pneumonia due to invasive S. pneumoniae infection. He reported recurrent fever for six months without any antibiotic treatment, which may have determined the further course of the syndrome. Echocardiography revealed massive native valve endocarditis, and the patient was considered for ultima-ratio cardiac surgery. Intraoperative aspect presented extensive affection of the aortic root with full destruction of aortic valve, mitral valve, and aortomitral continuity. The myocardium showed a phlegmonlike infiltration. Microbiologic testing of intraoperatively collected specimens identified penicillin-sensitive Streptococcus pneumoniae. S. pneumoniae is a very uncommon cause for infective infiltrative endocarditis and is associated with severe clinical courses. Austrian syndrome is even more rare, with only a few reported cases worldwide. In those patients, only early diagnosis, immediate antibiotic treatment, and emergent cardiac surgery can save lives.

Síndrome de Austrian / Austrian Syndrome: case report

Neste relato, é descrito o caso de um paciente masculino, 64 anos, sem história de etilismo, que se apresentou com a Tríade de Osler, que consiste no desenvolvimento de endocardite, pneumonia e meningite, por um mesmo agente. A síndrome é denominada síndrome de Austrian, quando a infecção for por Streptococcus pneumoniae. Serão discutidas as manifestações clínicas, fisiopatológicas e a terapêutica mais adequada para esse quadro. Tendo em vista a raridade do caso e a elevada morbimortalidade, serão enfatizadas a importância do diagnóstico precoce e o tratamento adequado, visando reduzir as complicações inerentes a essa doença.

In this report, we describe the case of a 64-year-old male patient, with no history of alcohol consumption, who presented the Osler's triad, which is the association of endocarditis, pneumonia, and meningitis caused by a single agent. This syndrome is called Austrian syndrome, when the infection is caused by Streptococcus pneumoniae. We discuss the clinical manifestations, the pathophysiology, and the therapeutic approach to this condition. Given the rarity of the condition and its high morbidity and mortality, the importance of an early diagnosis and an appropriate treatment to reduce the complications associated with this disease will be emphasized.

A clear CSF is not always a normal CSF.

A normal initial cerebrospinal fluid (CSF) study has been traditionally used to exclude the potential diagnosis of bacterial meningitis. However, cases of pyogenic meningitis in the absence of CSF pleocytosis have been reported in which smears for gram stain or CSF culture revealed the diagnosis of meningitis. In the presence of clinical signs of meningitis, an abnormal initial CSF study indicates a diagnosis of bacterial meningitis but a normal result may not necessarily exclude it and therefore, should not delay early institution of appropriate antimicrobial therapy.

The utility of the polymerase chain reaction assay for aetiologic definition of unspecified bacterial meningitis cases

Most patients with acute suppurative meningitis are otherwise healthy individuals with regard to immune mechanisms against invasive bacterial disease. This medical emergency is among the most dramatic and potentially ravaging diseases that affect humans, particularly young children. The illness often strikes suddenly, and can either result in death or leave the survivors with significant neurological dysfunctions. The demonstration of a bacterial aetiology is necessary for decisions regarding treatment and prophylaxis. Conventional bacteriological methods frequently fail to identify an agent, as a result of administration of antibiotics or delayed lumbar punctures. We investigated the major aetiologic sources of unspecified bacterial meningitis cases (G00.9, ISCD-10) by polymerase chain reaction (PCR)-based identification of Neisseria meningitidis (crgA), Streptococcus pneumoniae (ply) and Haemophilus influenzae (bexA) in cerebrospinal fluid samples. The multiplex PCR detected N. meningitidis in 92 percent, S. pneumoniae in 4 percent and H. influenzae in 1 percent of the 192 clinical samples assayed; 3 percent were negative for all three DNA targets. Bacterial DNA detection was found to be a valuable adjunct to enhance bacterial meningitis surveillance when the yield of specimens by culture is reduced. The implementation of PCR assays as a diagnostic procedure in Public Health Laboratories is perceived to be a significant advance in the investigation of bacterial meningitis.

Recent outbreak of meningococcal meningitis--a microbiological study with brief review of literature.

Meningococcal disease presents in various clinical forms, most common being meningitis and meningococcemia. A spurt of meningococcal cases was seen in medicine and pediatric wards of Dr. Ram Manohar Lohia Hospital during the recent outbreak from Dec 2005 - June 2006. These had presented either with the classical features of acute purulent meningitis or as fever with rash. The patients were investigated microbiologically for the causative organism which was identified as Neisseria meningitidis in 257 out of 531 cases (48.39%). The classic finding of gram negative diplococci on gram stain remained the mainstay of diagnosis. N. meningitidis isolates from culture were sensitive to all commonly used antibiotics.

Meningitis neonatal por Streptococcus pneumoniae atípico: Reporte de un caso y revisión / Neonatal meningitis caused by atypical Streptococcus pneumoniae: Case report and review

Streptococcus pneumoniae is a rarely recognized cause of neonatal sepsis and/or meningitis, but it is associated with substantial morbidity and mortality. Traditionally, S. pneumoniae is identified in the laboratory by demonstrating susceptibility to optochin. However, the emergence of optochin-resistant organisms makes definite identification difficult when only phenotypic tests are taken as markers. We present the case of a severe early-onset neonatal meningitis due to an atypical strain of S. pneumoniae. Laboratory methods utilized to certify this species diagnosis are discussed.

Streptococcus pneumoniae es una causa infrecuente de infección en el recién nacido y se caracteriza por gran capacidad invasora (sepsis, meningitis) y alta mortalidad. Tradicionalmente, esta bacteria se diagnostica en base a su susceptibilidad a optoquina. Sin embargo, la emergencia de cepas de S. pneumoniae resistentes a optoquina (atípicas) dificulta el diagnóstico sin utilizar varias pruebas diagnósticas, incluyendo las de biología molecular. Se describe el caso de una neonata con infección invasora causada por una cepa de S. pneumoniae atípico y se discuten los métodos empleados para certificar el diagnóstico de esta especie.

Diagnosis of Streptococcus pneumoniae meningitis by polymerase chain reaction amplification of the gene for pneumolysin

Diagnosis of bacterial meningitis has long been based on classical methods of Gram stain, serological tests, and culture of cerebrospinal fluid (CSF). The performance of these methods, especially culture and direct smear, is thwarted by failure to detect bacteria following administration of antimicrobial agents and reluctance to performance lumbar punctures at admission. Indeed, patients with meningitis frequently receive antibiotics orally or by injection before the diagnosis is suspected or established. Thus an alternative method has become necessary to help clinicians and epidemiologists to management and control of bacterial meningitis. We evaluate the application of a polymerase chain reaction-based (PCR) assay for amplification of pneumolysin gene (ply) to diagnosis of Streptococcus pneumoniae meningitis. The PCR assay sensitivity for CSF was 96 percent (95 percent confidence interval, CI, 90-99 percent) compared to a sensitivity of 59 percent for culture (95 percent CI 49-69 percent), 66 percent for Gram stain (95 percent CI 56-74 percent), and 78 percent for latex agglutination test (95 percent CI 69-86 percent); PCR specificity was 100 percent (95 percent CI 83-100 percent). PCR results were available within 4 h of the start of the assay. This molecular approach proved to be reliable and useful to identify this bacterium compared with other classical laboratory methods for identification of bacterial meningitis pathogens.

Neumoencéfalo, otitis media y meningitis a neumococo / Pneumocephalus, middle otitis and meningococcic meningitis

La meningitis bacteriana es una enfermedad con alta morbi-mortalidad, el germen prevalente es el Strep pneumoniae y constituye la complicación intracraneal más frecuente de la otitis media aguda en el adulto. La TAC de cerebro es de indicación habitual ante su sospecha, previa a la realización de la punción lumbar, y en el 13 por ciento de los casos, los hallazgos son compatibles con una disrupción de la barrera dural, de la que el neumoencéfaloi (NE) es una de las consecuencias. Se presenta un paciente con meningitis bacteriana aguda por neumococo, otitis media y NE, sin traumatismo, malformación, tumor o cirugía previa

Latex agglutination test in the diagnosis of pyogenic meningitis.

Samples of cerebrospinal fluid (n=204) from pediatric patients with clinically suspected pyogenic meningitis were examined by direct microscopy, bacterial culture and Latex Agglutination Test (LAT). Latex Agglutination Test was done for detection of antigen of Streptococcus pneumoniae and Haemophilus influenzae type b. Among 38 LAT positive cases, culture and/or gram stain was positive in only 20 cases and 18 cases were detected exclusively by LAT. Besides, LAT was useful in detecting the pre-treated cases as 11 out of 55 samples from pre-treated cases were positive by LAT in comparison to culture and/or Gram stain which detected only 4 of 55 cases. LAT is simple, rapid and more reliable test.

Detection of pneumolysin in cerebrospinal fluid for rapid diagnosis of Pneumococcal meningitis.

BACKGROUND & OBJECTIVES: Pneumolysin, a toxin produced by Streptococcus pneumoniae is associated with virulence and is found in all invasive isolates. Its role as a diagnostic tool has recently been exploited. Most of the methods used are based on molecular techniques and are not cost-effective. The present study was undertaken to evaluate a simple, rapid and cost-effective method to detect pneumolysin in CSF as a diagnostic test for pneumococcal meningitis. METHODS: A total of 75 CSF samples from children with presumptive diagnosis of acute pyogenic meningitis or encephalitis were subjected to Gram stain, culture and pneumolysin detection by Cowan 1 staphylococcal protein A co-agglutination technique. RESULTS: Pneumolysin was detected in 26(78.8%) of 33 culture proven CSF samples and 4(9.5%) of 42 culture negative samples. Antigen detection by Co-A had a specificity of 90 per cent and a sensitivity of 79 per cent when compared with culture. Compared to Gram stain, pneumolysin Co-A had a specificity and sensitivity of 91.0 and 92.0 per cent respectively. INTERPRETATION & CONCLUSION: Detection of pneumolysin was found to be a simple, low cost antigen detection assay for rapid diagnosis of pneumococcal meningitis, for routine use in the developing countries.

Community acquired-bacterial meningitis in adults.

We reviewed the charts of all patients > or = 15 years of age or older in whom community acquired-bacterial meningitis was diagnosed at Srinagarind Hospital, Khon Kaen, Thailand from 1984 through 1998. Eighty-five patients were included in this study. The clinical manifestation was acute meningitis with CSF neutrophilic pleocytosis and low glucose content. Gram's staining of CSF was positive in 79%. The most common pathogens were Streptococcus pneumoniae (28%) and Escherichia coli (14%) respectively. The overall mortality was 34%.

Meningitis neonatal: streptococcus B-hemolítico grupo B / Neonatal meningitis: group B betahemolytic streptococci

Las infecciones ocasionadas por estreptococos del grupo B (SGB), representan a nivel mundial la primera causa de morbimortalidad neonatal. El objetivo del trabajo es determinar, si en nuestro medio este microorganismo también representa el principal germen implicado en meningitis neonatal. Se realizó un trabajo retrospectivo-descriptivo, donde se revisaron 1057 historias de recién nacidos ingresados en el Servicio de Patología Neonatal, del Hospital "J.M. de los Ríos" durante el lapso enero 1990- diciembre 1994; encontrándose 41 pacientes con el diagnóstico clínico y bacteriológico de meningitis neonatal, donde 23 casos (56,1 por ciento) fueron ocasionados por SGB. de los 23 pacientes con SGB, se encontró predominio del sexo masculino (3:1), forma clínica predominante de síndrome tardío (94.74 por ciento) y como principales factores de riesgo RPM (60.86 por ciento) y prematuridad (17 por ciento)

Detection of antipneumolysin in invasive childhood pneumococcal infections.

Antibody levels against pneumolysin, a virulence factor in pneumococcal infections were evaluated by a neutralization test, using crude pneumolysin. A study population of 28 hospitalised children with culture proven pneumococcal meningitis and pneumonia were tested for detection of antipneumolysin antibodies in their serum. Results were compared with age and sex matched controls who were admitted with infections other than pneumococcal. Geometric mean titer (GMT) of antipneumolysin in serum of patients with pneumococcal infections showed a significant difference when compared with controls, GMT of 196.1 and 185.2 were noted in patients with meningitis and pneumonia respectively, in contrast to a titer of 40.32 among controls. A difference of more than 4-fold antibody titers between patients and controls was considered significant. Detection of antipneumolysin in serum can therefore be considered as a useful laboratory investigation in diagnosing invasive pneumococcal infections.

Use of oligonucleotide probes for meningococcal serotype characterization

No presente trabalho nos examinamos o uso potencial de sondas de oligonucleotideos para caracterizar sorotipos de Neisseria meningitidis sem o uso de anticorpos monoclonais (MAbs). A diversidade antigenica da proteina PorB forma a base do metodo de sorotipagem, todavia, o atual painel de MAbs utilizados, sub-estima em no minimo 50 por cento a diversidade desta proteina devido a falta de reagentes para as varias regiöes variáveis (VRs) da proteina PorB ou porque varias variantes das VRs nao sao reagentes com os MAbs disponíveis. Nos analisamos o uso de sondas de oligonucleotideos para caracterizar os sorotipos 10 e 19 de N. meningitidis. O gene porB da cepa prototipo do sorotipo 10 foi sequenciado e alinhado com outras 7 sequencias de diferentes sorotipos, e as individuais VRs foram entäo analisadas. Os resultados com as sondas 21U (VRI-A) e 615U (VR3-B) contra 72 cepas de N. meningitidis os MAbs 19 e 10 respectivamente. E possivel o uso de sondas para a caracterizaçäo dos sorotipos e podemos tipar 100 por cento da diversidade da VR do gene porB. Trata-se de um metodo simples, rapido, e especialmente util para a analise de um grande numero de amostras