Cerebrovascular Complications of Pediatric Pneumococcal Meningitis in the PCV13 Era

Abstract

A previously healthy, full-term 5-month-old girl presented to the emergency department with a 1-day history of fever to 103°F, emesis, poor feeding, and progressive lethargy. She had recently started day care. The patient had received her routine 2-and 4-month childhood vaccines on schedule, including the 13-valent pneumococcal conjugate vaccine (PCV13). Initial examination revealed decreased responsiveness, rightward gaze preference, decreased movement of the left side, and positive Brudzinski sign. Laboratory testing is as in Table 1. Ceftriaxone and vancomycin were started at meningitic dosing. Cerebrospinal fluid grew Streptococcus pneumoniae serotype 33F, a nonvaccine serotype. Case 2A previously healthy 21-month-old boy presented to the emergency department with a 1-day history of fever to 103°F, emesis, cough, and lethargy. Rapid influenza testing was positive for influenza A, and oseltamivir was started. History was notable for day care attendance and multiple sick contacts. He was fully immunized, including PCV13.The next morning, he had a brief seizure with eye deviation and generalized convulsions, and became obtunded. Simultaneously, blood culture grew gram-positive cocci in pairs and chains. He returned to the emergency department, where he had right-sided weakness, posturing, rightward eye deviation, and meningismus as well as further seizures requiring lorazepam and fosphenytoin. Laboratory testing is as in Table 1. Ceftriaxone and vancomycin were started at meningitic dosing. Cerebrospinal fluid grew S pneumoniae serotype 15B, a nonvaccine serotype.

Complicated Pneumococcal Meningitis: A Diagnostic and Therapeutic Challenge

“…Certain risk factors such as cochlear implants, skull fractures, and complement system deficiency have been associated with both recurrent and severe pneumococcal meningitis [3, 4]. Overall, vaccination with PCV-13 has led to a decline in infection rates; however, both antimicrobial-resistant and nonvaccine serotypes are proving themselves to be a growing threat [8-12].…”