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Invasive Streptococcus pneumoniae Infection in an Afebrile Adolescent With HIV

 

    Authors:
    Sandra M. Camacho-Gomez, MD, and Yekaterina Sitnitskaya, MD
    Department of Pediatrics, NYC Health + Hospitals/Lincoln, The Bronx, New York

    Citation:
    Camacho-Gomez SM, Sitnitskaya Y. Invasive Streptococcus pneumoniae infection in an afebrile adolescent with human immunodeficiency virus [published online November 14, 2017]. Consultant360.

     

    Introduction

    The risk of invasive pneumococcal disease (IPD) is increased in immunocompromised persons, including HIV-infected persons, compared with immunocompetent persons.1-4 Therefore, despite a significant reduction of IPD cases in the HIV-infected population in the highly active antiretroviral therapy (HAART) era5 and in the post­–pneumococcal-conjugate vaccine (PCV) era, the risk of IPD is generally still higher in immunocompromised patients.6 However, the clinical presentation is the same in those with and without HIV infection.4 Streptococcus pneumoniae is a major cause of bacteremia, which presents as fever with or without focus. We present a very unusual case of afebrile S pneumoniae lobar pneumonia and empyema in a fully vaccinated, infected adolescent.

    Case Presentation

    An 18-year-old boy with perinatal HIV and hepatitis C coinfection, cirrhosis, coagulopathy, and chronic thrombocytopenia, presented with 4 days of cough and 2 days of right chest pain and dyspnea, but no fever. The patient was not adherent to antiviral medications. His latest CD4 lymphocyte count was 11%, and his viral load was 28,300 copies/ml.

    The patient had received 2 doses of PCV-13 and 3 doses of pneumococcal polysaccharide vaccine (PPV-23), most recently at age 16 years. He had no previous history of IPD.

    The patient appeared ill but he was alert and oriented. His temperature was 37°C, respiratory rate was 24 breaths/min, heart rate was 99 beats/min, blood pressure was 115/48 mmHg, and oxygen saturation was 98% on room air.

    The patient had subcostal, intercostal and suprasternal retractions, decreased breath sounds, and tracheal breathing in the right base. The spleen was palpable 2 cm below the costal margin. The rest of the physical examination findings were unremarkable.

    The white blood cell (WBC) count was 7800/µL, the platelet count was 38 × 103/µL, blood urea nitrogen level was 36 mg/dL, and creatinine level was 3.05 mg/dL. A chest radiograph showed right lower-lobe consolidation and moderate effusion, findings that were confirmed with chest ultrasonography (Figure).

    chest ultrasonography

    Initial treatment included ceftriaxone, azithromycin, and trimethoprim-sulfamethoxazole. A chest tube placed for 5 days yielded drainage of approximately 4000 mL of purulent material. The pleural examination showed gram-positive cocci in pairs and 4+ WBCs, but cultures had no bacterial growth. Blood cultures grew pan-sensitive S pneumoniae.

    The patient was discharged after 10 days of treatment with oral amoxicillin. At follow-up 2 weeks later, he was asymptomatic and had normal findings on lungs auscultation. The patient had restarted HAART and reported full medication adherence.

    Discussion

    Current guidelines recommend immunizing patients at risk for IPD with PCV-13 and PPV-23.7 When it was introduced as PCV-7, the pneumococcal vaccine led to a more than 90% reduction in IPD,8 and later PVC-13 further broadened protection.9,10 In the past, among HIV-infected persons, bacterial pneumonia occurred with increased frequency with any CD4 lymphocyte count,2,3,11 but it developed more frequently among those with CD4 lymphocyte count of less than 200/mm3.3

    Although our patient had been appropriately vaccinated, he was not adherent to HAART and had a significant decline in the CD4 lymphocyte count during the preceding year; this probably contributed to the development of IPD. In addition to boosted pneumococcal vaccination, adherence to HAART must encouraged in HIV-infected youth, with emphasis on its role in prevention of severe illness requiring hospitalization and invasive procedures. The absolute leukocyte count is seldom over 15,000 cell/mL, and neutropenia may be more common in patients with HIV infection.2,11 It is more helpful in an HIV-infected child with a fever to analyze the relative change in WBC from baseline as a predictor of bacteremia.4

    Bacteremic pneumococcal pneumonia is a febrile illness.12,13 There was a single case report of a pediatric patient with sickle cell disease who was afebrile despite S pneumoniae meningitis and bacteremia.14 Here, we report a case of afebrile IPD in an immunocompromised patient with HIV infection.  

    Conclusion

    Although extremely rare, afebrile IPD is possible and should be considered, especially in an immunocompromised host.

    References
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