Clinical manifestations of purpura-producing Streptococcus pneumoniae may mimic meningococcemia. The pathogenesis of S. pneumoniae purpura has been elucidated, but clinical cases of benign purpura due to this organism are rare. We report the first case of purpura-producing S. pneumoniae occurring in the setting of uncomplicated community-acquired pneumonia in an immunocompetent adult. (Infect Dis Clin Pract 2004;12:288-290)
CASE REPORTAn 18-year-old male presented with a 3-week history of rhinorrhea that progressed to fevers, a dry cough, and chills over the 4 days before admission. The patient noted a rash that began on both ankles and spread proximally to his distal thighs 2 days before admission. The rash was not painful or pruritic. He denied headache, confusion, dyspnea, or chest pain. He was without any significant past medical or surgical history and was on no medications. He had moved to San Diego, CA, from Texas one month before presentation after enlisting in the US Marines. He reported no exposures to ticks or animals. Standard Basic Training-related immunizations 1 month before admission included the pneumococcal and meningococcal vaccines. On examination, his temperature was 38.28C, pulse of 78 beats per minute, blood pressure 110/59 mm Hg, respiratory rate of 20 breaths per minute, and oxygen saturation of 99%. He was ill-appearing. His lungs had decreased breath sounds in the left lower lobe with accompanying crackles. Skin examination showed a nonblanching, nonpalpable, purpuric rash extending from both ankles to his thighs (Fig. 1). He had no other cutaneous findings, and the remainder of his examination was normal.Laboratory values included a white blood cell count of 15,100 cells/mm 3 , hemoglobin of 13.2 mg/dL, platelets 263,000, and a normal chemistry panel. Liver function tests were normal except for an albumin of 2.6 mg/dL. International Normalized Ratio was elevated at 1.4 with a prothrombin time of 13.8 seconds, and partial thromboplastin time of 34.3 seconds; a disseminated intravascular coagulation panel was negative. The elevated INR resolved over 48 hours without any specific therapy. Chest radiograph demonstrated a left lower lobe infiltrate without effusion or adenopathy.The patient was treated with ceftriaxone 2 g intravenously and levofloxacin 500 mg daily for community-acquired pneumonia. He continued to have temperatures of up to 39.18C for the first 36 hours and then became afebrile. Given the possibility of Neisseria meningitidis, 80 men who slept in the same room in the barracks received a single dose of levofloxacin (500 mg).A workup for the etiology of the patient's illness included 2 sets of blood cultures; Chlamydia pneumoniae and Mycoplasma pneumoniae IgM and IgG serologies; viral cultures for adenovirus, respiratory syncytial virus, influenzae, and parainfluenzae (Rhinoprobe); an antistreptolysin O titer; and throat culture for group A streptococcus and N. meningitidis. All of these tests were negative. The patient was unable to produce a sputum sample despite multi...