Pre-school of 2 years 2 months, male, with no significant morbid history.
The vaccination schedule was established according to the Chilean National Immunization Program (PNI) per day, including three doses of pneumococcal vaccine 10-valent at 2-4 and 12 months of age.
He had also received extra-PNI anti-cancer agents and hepatitis A vaccines. He had been attending kindergarten for a year.
The clinical picture began 72 hours prior to consultation, characterized by general malaise associated with fever and explosive vomiting on two occasions.
Febrile persisted up to 38.2°, increasing the commitment of the general state, so he consulted in Emergency Service, where was found a patient compromised of consciousness, Glasgow 9, fever (130/ borderline capillary blood pressure), with increased blood pressure.
Septic shock and probable acute bacterial meningitis were diagnosed.
Shock management was initiated with iv volume and ventilatory assistance.
Due to consciousness compromise, a brain CT scan was performed, which showed no signs of endocraneal hypertension, followed by a lumbar puncture that gave rise to turbid CSF.
The cytochemical analysis was: hypoglycorrhachia (glucose < 10 mg/dl), proteinorrhachia 515 mg/dl, erythrocytes 10/mm3, leukocytes 80/mm3 (60% polymorphonuclear).
His general tests showed a hematological count with 5800 leukocytes/mm3 (62% segmented; 25% eosinophils), platelets 224,000/mm3, hematocrit 29%, hemoglobin 9.8 g/dl 270 mg/dl and C-reactive protein (CRP)
Direct Gram stain of CSF showed abundant cocci.
Antimicrobial therapy with intravenous ceftriaxone was started one hour after admission to the ED.
100 mg/kg/day, in a daily dose, after taking blood cultures.
Suspicion of etiology pneumococci anterior was added to the dexamethasone IV scheme.
0.6 mg/kg/day and 60 min after starting corticosteroids, vancomycin 60 mg/kg/day.
1.
The patient was admitted to the ICU with a severe evolution, requiring mechanical ventilation, hemodynamic compromise, intense metabolic acidosis, requiring vasoactive support with norepinephrine.
Phenobarbital was added due to the appearance of a seizure syndrome.
The installation of a syndrome of inappropriate antidiuretic hormone secretion was managed with desmopresin, with regular response.
The pharmacokinetic monitoring of vancomycin showed basal and peak plasma concentrations that determined an area under the curve (AUC 24hrs/CIM=1 mg/L) of 423 mg x hr/L where the therapeutic exposure of the drug was interpreted as effective.
In both hemocultives and CSF, S. pneumoniae was isolated with MIC by epsilo (E-test) penicillin 1.5 μg/mL and a cefoxime 1.0 μg/mL and vancomycin hydrochloride.
Considering the in vitro susceptibility of the strain to cefoxime, referring to blood, vancomycin was suspended 48 h after its initiation.
A new series of two follow-up hemocultives 48 h after admission was reported as negative.
The behavior of their laboratory parameters is summarized in Table 1.
1.
Hto: hematocrit.
Hb: hemoglobin.
CRP: C-reactive protein.
1.
The patient had a torpid evolution, with marked neurological compromise, absence of corneal, oculocephalic and oculo-palpebral reflex, mydriasis pupils, without response to light or painful stimuli.
A new CT scan performed 24 h after admission showed extensive diffuse cerebral edema, herniation dural puncture and linear hyperdensity of brain sulci with normal doppler flow, which prevented a new lumbar realization.
Electroencephalographic monitoring 48 hours after the patient was admitted showed little diffuse activity and a non-gatilloscopy showed apnea episodes.
On the 6 day of evolution, a new EEG was performed, which showed the absence of electrical activity, without reactivity to sound stimulus or pain, and brain death was diagnosed.
The report of the reference laboratory (Instituto de Salud Pública-ISP) that the strain of S. pneumoniae isolated from CSF was resistant to penicillin (ICM 8 μg/mL) microcrystalline broth/mL
Subsequently, S. pneumoniae serotype 19 A was confirmed from the ISP.
A study of antipneumococcal antibodies showed low concentrations (< 1.3 mg/ml) for six of the ten serotypes evaluated.
