PNEUMOCOCCAL MENINGOENCEFALITIS IN a 50-DAYs-OLD BABY WITH LETHAL OUTCOME – A CASE REPORT

1. PNEUMOCOCCAL MENINGOENCEFALITIS IN a 50-DAYs-OLD BABY WITH LETHAL OUTCOME – A CASE REPORT PekovaL1,2, P. Parousheva1, G. Josifova2, M. Dimitrova2 1-Trakia University, Medical Faculty, Dept. of Infectoious Diseases 2- University Hospital, Clinic of Infectious Diseases

2. Streptococcuspneumoniae is a Gram+bacterium, which may colonize nasopharynx of healthy careers without any symptoms.It affects predominantly respiratory tract,sinuses, nasal and oral cavity but in immunocompromised patients it may engaged other locci.

3. It is an usual agent of pneumonia in society, meningitis in the small age and adults, septicemia in HIV+. Its clinical spectrum involves rhinitis, conjunctivitis, sinuitis, bronchitis, medial otitis, osteomielitis, septic arthritis, endo- andpericarditis, peritonitis, cellulitisand brain abscess.Infecting is carried out through direct contact by drops, splashes and secrets during the speech, cough and cold.

4. Distribution of Streptococcus Pneumoniaein the small age is as follows: 3-5 months - more often are meningitis6-12 months – medial otitis13-18 months– pneumonia

5. It is known that in the age under 2 years the common agents of meningitis are Gram- bacteria -about 80% . In the rest 20% leading position has S. pneumoniae..

6. In the age between 2-6 months 73% of neuroinfectionsare caused by S. pneumoniae. Distribution of all 92 serotypes of S. pneumoniae depends on age, season and geographic area.

7. We present a severe case of S. pneumoniae meningoencephalitis in a 50-days-old fed-breast child from Stara Zagora, Bulgaria. There was a lethal outcome. Clinical, laboratorial, microbiological, instrumental and epidemiological investigations were performed.

8. S. S. S. was a suckling boy who is conceived by „in vitro”, born by sectio Caesarea after 9-years sterility. His birth weight was 4050 g.On the 5-th minute his APGAR was 5. Mechanical ventilation and oxygenation were administered. Up to his 50-th day of life obligatory vaccines according to Bulgarian immunization calendar had been applied.

9. On Sept. 22-nd 2016 he was restless and irritable with temperature up to 39,1˚С but his appetite was not been reduced. He had been examined by pediatrician and symptomatic therapy was recomended.

10. OnSept. 24-th 2016 he vomited several timesand had unstable faeces twice.At the day of hospitalization he was languid and refused food.Two weeks before his parents had mild catarrh and malaise.

11. On admission at the Clinic of Infectious diseases of the University hospital he looked disturbed and intoxicated with temperature 37,8 С. His skin was pale, there were sore throat and furred tongue. There were not enlarged lymph nodes.

12. His somatic status was normal. Large fontanelle was 10 x10 mm without prominence. Except exaggerated tendon reflexes there were no neurological meningeal signs. Two hours after admission the patient demonstrated four consecutive convulsions and became soporous, GCS=6-7.

13. CSF showed low level of glucosis, pleocytosis and high protein.Tabl. 1. Microbiological cultivation of CSF showed growth of S. pneumoniae. Clinical presentation, laboratorial findings and epidemiological analysis confirmed the diagnosis S. pneumoniae meningoencephalitis.

14. Tabl.1. Laboratorial changes in CSF

15. On the second day the respiration disorders called for pulmonary ventilation. The status worsened – coma cerebralis.

16. In spite of oxygen supply partial pressure of carbon dioxide was high.

17. Tabl.2. Changes in blood-gas analysis and ionogram

18. Tabl. 3. Laboratorial investigations of complete blood count

19. Tabl. 4. Changes at biochemical indicators

21. THERAPY Ethiological: For the first two days – combination Medaxon 2 x 500 mg i.v+Amikacin2 x 40 mg. i.v., after that: Meronem3x200 mg i.v., Penicillin4 x 1 250 000 E i.v. Amikacin 2 x 40 mg i.v.

22. Pathogenetical: Sol. Mannitholi 10% 4 x 30 ml i.v. Dexamethasone 3 x 1 mg i.v. Sol. KCl 15% Sol. NaHCO3 8,4% Dopamine

23. BIOPRODUCTS Fresh frosen plasma Erythrocyte concentrat Humman albumin Immunovenin

24. Independently of recent therapeutic progress S. pneumoniae meningoencephalitis leads to high mortality and severe neurological sequels in survivors.

25. Lethal outcome in S. pneumoniae meningitis was reduced almost 5times – from 24,1% to 5,5% due to impressive therapeutic progress as pointed Buchholz G et al. in 2016 г. was confirmed of that.

26. The fact that 44,2% of survivors after S. pneumoniae meningitis recovered totally gave ground for searching new therapeutic options.

27. It was known that 10-15 serotypes were responding for 80-90% of all cases of pneumococcal disease in the children under 5-years old. Two vaccines – Sinflorix and Pneumo-23 – were accessible for protection against 85-97% of all strains of S. pneumoniae.

28. Sinflorixis an obligatory vaccine at Immunization calendar of Republic Bulgaria. It was applied after second month three times at interval of 30 days. Six months later forth buster dose was given. S.S.S. was a 50-days-old when he fell ill, so he was in under-vaccinating age.

29. Microbiological investigation showed S. aureus of parents nasal swabs. We supposed that S. pneumoniae was suppressed by S. aureus at parents nasopharynx. Being healthy careers of S. pneumoniae they were the eventual source of infection.

30. In conclusion: Applying of vaccine against S. pneumoniae for adults – Pneumo-23, Pneumovax 23, or Prevenar 13 - could eliminate translation of infection.

31. THANK YOU FOR ATTENTION!