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Journal of Clinical Microbiology, January 2008, p. 392, Vol. 46, No. 1
0095-1137/08/$08.00+0     doi:10.1128/JCM.02005-07
Copyright © 2008, American Society for Microbiology. All Rights Reserved.

LETTER TO THE EDITOR

Mortality from an Uncommon Serotype of Streptococcus pneumoniae with an Unusual Presentation{triangledown}


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LETTER
 
We encountered a case in which an 81-year-old man received polyvalent Pneumovax 23 vaccine (Merck, Whitehouse Station, NJ) but died of an unusual presentation of infection from a serotype of Streptococcus pneumoniae. He presented with a chief complaint of lethargy without cough or sputum. He developed shaking rigor but was afebrile. His white blood cell count was normal. Blood cultures were negative. Radiographic studies showed a right pleural effusion. A thoracentesis produced 800 ml of fluid which had 94,000 neutrophils/µl (pH 6.55). After the patient was admitted to the intensive care unit, he died.

An autopsy confirmed the presence of fluid in the right chest cavity. Cultures of the pleural fluid were positive for Streptococcus pneumoniae. Further testing identified the bacteria as serotype 38. The lung parenchyma did not show bronchopneumonia. Lung culture showed normal flora.

This patient demonstrated infection by a serotype of S. pneumoniae for which polyvalent pneumococcal vaccine would not have provided protection. The capsular polysaccharides covered are 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F (pneumococcal vaccine polyvalent vaccine package insert; Merck, Whitehouse Station, NJ). The rare serotype 38 may be related to the bacteria's variant distribution in the chest and the unusual clinical course. Such a distribution of infection has been described previously and was attributed to hematogenous seeding of the pleural space (1). Our patient's presentation also suggests that the original site of S. pneumoniae infection may not necessarily have been the adjacent lung.

S. pneumoniae infection is one of the most common causes of death from pneumonia (2-4). In addition to age, risk factors for S. pneumoniae infection include lung disease, dementia, seizure disorder, smoking, overcrowding, and other factors (3). The current vaccine for the treatment of S. pneumoniae infection incorporates capsular polysaccharides from the most common serotypes, (3-4), although many more serotypes are recognized. The effectiveness of the vaccine in treating adults ranges from 60 to 70% (4).

Although vaccination could not prevent disease in this man, vaccination is generally an effective tool for reducing mortality from pneumonia. In addition to the polyvalent vaccine, new approaches include improved vaccines with broader coverage of polysaccharide serotypes, protein-polysaccharide conjugate vaccines, DNA-based vaccines, and vaccines specific to enzymes such as surface proteins A and C, hyaluronate lyase, pneumolysin, and neuraminidase (2, 4).


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FOOTNOTES
 
{triangledown} Published ahead of print on 24 October 2007. Back


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REFERENCES
 
    1
  1. Bennett, M. R., P. C. Fiehler, and D. L. Weinbaum. 1987. Occult pneumococcal bacteremia and empyema without preceding pulmonary parenchymal involvement. South. Med. J. 80:774-777.[CrossRef][Medline]
    2. 2
  2. Jedrzejas, M. J. 2001. Pneumococcal virulence factors: structure and function. Microbiol. Mol. Biol. Rev. 65:187-207.[Abstract/Free Full Text]
    3. 3
  3. Marrie, T. J. 1999. Pneumococcal pneumonia: epidemiology and clinical features. Semin. Respir. Infect. 14:227-236.[Medline]
    4. 4
  4. Pneumococcal vaccines: World Health Organization position paper. 1999. Can. Commun. Dis. Rep. 25:150-151.[Medline]
Henry J. Carson*
Weland Clinical Laboratories
1911 1st Avenue SE
Cedar Rapids, Iowa 52406

Robert F. Weis
Unity Health Care
1518 Mulberry Avenue
Muscatine, Iowa 52761-3499

* Phone: (319) 366-1503 Fax: (319) 366-6976 E-mail: hjcmd{at}earthlink.net

Journal of Clinical Microbiology, January 2008, p. 392, Vol. 46, No. 1
0095-1137/08/$08.00+0     doi:10.1128/JCM.02005-07
Copyright © 2008, American Society for Microbiology. All Rights Reserved.




This Article
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Right arrow Alert me when this article is cited
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