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NEONATAL HAND ABSCESS, OSTEOMYELITIS AND MENINGITIS CAUSED BY STREPTOCOCCUS PNEUMONIAE

1998; Lippincott Williams & Wilkins; Volume: 17; Issue: 8 Linguagem: Inglês

10.1097/00006454-199808000-00023

1532-0987

Eli M. Eisenstein, Benjamin Gesundheit,

Bacterial Infections and Vaccines

Streptococcus pneumoniae is a frequent cause of bacteremia and invasive infections including pneumonia, meningitis and osteomyelitis in infancy and childhood. However, only rarely does this organism cause subcutaneous infection or localized abscess formation. Furthermore it has not been reported as a cause of osteomyelitis in the neonatal period. In this report we describe a case of late onset neonatal bacteremia with meningitis accompanied by subcutaneous abscess and osteomyelitis of the hand caused by S. pneumoniae. Case report. A 27-day-old male infant was hospitalized because of fever with swelling and decreased movement of the left hand, which began 3 days previously. He was delivered at term after an uncomplicated pregnancy to a healthy 34-year-old para 4, gravida 4 mother. The parents are first cousins. The weight at birth was 3500 g and the perinatal course was uncomplicated, without abnormal vaginal discharge or signs of chorioamnionitis. He was breast-fed and gained weight normally over the first 3 weeks of life. When the infant was 24 days old a pediatrician noted redness and swelling of the left hand. The infant was referred for hospitalization, but the parents elected to take him home, where he remained active and continued to feed well. Three days later he felt warm to touch and was brought to the emergency department of our hospital. There was no history of needle insertion or other trauma to the hand. On arrival the infant appeared alert and well. Rectal temperature was 38.8°C. Physical examination was notable for normal pulse and respirations, a normotensive fontanel and a red, warm, swollen and tender left hand, without signs of trauma. Its circumference was 12 cm, as compared with 9 cm for the right hand. The white blood cell count was 13 100/μl with 73% neutrophils and 21% lymphocytes. The blood glucose concentration was 5.4 mmol/l. Examination of the cerebrospinal fluid disclosed a protein concentration of 1031 mg/l, a glucose concentration of 2.6 mmol/l, 200 neutrophils/μl and numerous Gram-positive diplococci in pairs and chains. Treatment was begun with intravenous ampicillin and gentamicin. The following morning cultures of blood, cerebrospinal fluid and pus aspirated from the hand grew alpha-hemolytic cocci which were presumptively identified as S. pneumoniae based on colony morphology and Gram's stain. In accordance with antimicrobial sensitivity data in our hospital that indicate that 23% of pneumococcal isolates are relatively resistant to penicillin, intravenous vancomycin was added. The bacteria were confirmed to be S. pneumoniae by optichin susceptibility and solubility in deoxycholate. Because all strains were sensitive to penicillin with similar MICs (<0.06 μg/ml), therapy was changed to intravenous penicillin G, 400 000 units/kg/day. Studies performed at the Israel Ministry of Health by the Quellung reaction with type-specific anti-pneumococcal sera showed the organism to belong to serotype 2. During the first 3 days of hospitalization, 8 ml of pus were aspirated from the dorsal aspect of the left hand. A 99Tc scan showed increased uptake in the left metacarpal bones. The diagnosis of osteomyelitis was confirmed radiographically 10 days later with a periosteal reaction of the fourth left metacarpal bone. Within 48 h after therapy was begun, the infant was afebrile. He remained active, continued to feed well and gained weight throughout the hospitalization. Treatment with intravenous penicillin was continued for 4 weeks. After discharge from the hospital oral penicillin VK was prescribed for an additional 14 days. The infant made a full recovery from his illness. Function of the involved hand, his developmental examination and audiologic testing performed by measurement of brainstem auditory evoked responses were normal 1 and 5 months later. Discussion. Subcutaneous abscesses resulting from transcutaneous inoculation are not rare during the neonatal period.1 In contrast localized abscesses as a consequence of hematogenous seeding during neonatal septicemia occur far less commonly. Such infections have been described as a feature of staphylococcal sepsis throughout life.2 In addition a case of bacteremia with hand abscess closely resembling the infant we describe was reported to be caused by Haemophilus influenzae.3 S. pneumoniae rarely causes soft tissue infection at any age.4 Connective tissue disease has been proposed as a risk factor for these infections in adults.5 This baby's abscess occurred adjacent to osteomyelitis of the metacarpal bones of the left hand. Although it seems reasonable to assume that the infection spread locally between bone and soft tissue, we do not know whether the subcutaneous abscess of osteomyelitis occurred first. S. pneumoniae is a well-described cause of osteomyelitis during infancy.6 However, to our knowledge this is the first report of pneumococcal osteomyelitis during the first month of life. In most instances neonatal bacteremia with S. pneumoniae presents as fulminant sepsis, characterized by respiratory distress and shock beginning within 24 h after birth. This form of disease is associated with maternal vaginal cultures positive for S. pneumoniae and in some instances with presence of vulvovaginitis or chorioamnionitis. Mortality for this condition exceeds 50%. In contrast when disease begins after 48 h of life, as in the our case, the clinical features are those of late onset neonatal sepsis, including meningitis, absence of respiratory distress and a less fulminant course.7, 8 The unusual clinical features in this case prompted us to examine factors that influence host defense against pneumococcal infection. We found no evidence of asplenia, hematologic abnormality, HIV infection or hypogammaglobulinemia. This infant's disease was caused by S. pneumoniae serotype 2, a serotype which causes <2% of invasive pneumococcal infections in Israel.9 Because there is evidence that transplacentally acquired maternal antibody may protect against pneumococcal disease,10 we hypothesized that absence of antibody against this uncommon serotype may have predisposed this infant to systemic infection. To test this possibility we examined maternal serum and convalescent infant serum for antibodies against an S. pneumoniae isolate obtained from cultures of the infant's blood using the Quellung reaction. Both maternal and infant sera were nonreactive whereas control serotype-specific antiserum produced a positive test. These results indicate that it is unlikely that the infant received significant titers of maternal anti-pneumococcal serotype 2-specific antibodies by transplacental passage. Also they indicate that the infant did not mount a substantial humoral response against pneumococcal capsular polysaccharide despite systemic disease, a typical finding in infants younger than 2 years of age. Thus it seems likely that lack of opsonizing antibody directed against pneumococcal capsular polysaccharide antigen contributed to susceptibility to invasive disease in this infant. Eli M. Eisenstein, M.D. Benjamin Gesundheit, M.D. Hebrew University Medical School (EME) and Department of Pediatrics (EME, BG); Hadassah University Hospital at Mount Scopus; Jerusalem, Israel