Infectious Diseases Conference

1
Infectious Diseases Conference

• July 31, 2006
• Laurence B. Givner, MD
• Pediatric Infectious Diseases

2

• 5 y/o AA female
• 1-20-06 Fever began to 104.7 then cough,
  tachypnea
• 1-23-06 Seen by PCP
• CXR L lower lobe and lingular pneumonia
• Azithromycin (pen-allergic)
• 1-25-06 Incr WOB, returned to PCP, then ED

3
ED 1-25-06

• T103.8, P161, R59, O2 sat 89 on RA
• Mod resp distress w/flaring and retractions
• Absent breath sounds on left
• WBC 17.0 P70 B15, hgb 11.7, pl 321
• BMP Na 137, K 4.3, Cl 102, CO2 17, BUN 14, Cr
  0.7
• Blood culture drawn
• CXR Left hemithorax opacified w/midline shift to
  R

4
1/23/06
5
1/25/06
6
Early Course

• Vancomycin and clindamycin begun
• Adm to Peds Intermediate Care Unit
• Diagnostic Thoracentesis
• 15 ml straw-colored fluid
• WBC 2750 (100 polys), RBC 6
• Prot 5.4, LDH 2500
• Gram Stain 1GPC, 1GPR

7
Course (Cont)

• 1-26-06
• WBC 24.9 P51 B39, hgb 10.3, pl 146.
• CT Pneumonia, Large L pleural effusion w/o
  loculations
• Chest tube 100 ml fluid
• 1-27-06
• OR for VATS- diffuse bleeding at op sites-
• surgery terminated
• WBC 31.2, hgb 6.2, pl 23. PT/PTT 13.2/40.3,
  fibrinogen nl.
• BUN 58, Cr 2.7 (Tenckhoff placed 1-28-06)

8
Other History

• PMH
• Pen-allergic
• Immuniz UTD incl Prevnar x 4
• Soc Hx
• Lives in Kville with parents and 3 sibs
• Attends pre-school
• No known sick contacts
• No pets, travel

9
Questions?

• What are the usual pathogens?
• Why the dramatic deterioration in status?

10
Cultures

• Blood and initial pleural fluid
• Streptococcus pneumoniae
• R Pen, cefuroxime, clindamycin
• S Ceftriaxone

11
Hemolytic Uremic Syndrome

• Most common cause of ARF in children
• Most often due to E. Coli 0157H7
• Also caused by S. pneumoniae

12
Pneumococcal HUS - Pathogenesis

• Pneumococci produce neurominadase removing
  N-acetyl neuraminic acid from cell membrane
  surfaces expressing the Thomsen-Friedenreich
  antigen present on RBCs, platelets and glomerular
  capillary walls. Antigen-antibody interaction
  results in hemolysis, thrombocytopenia and renal
  microangiopathy.

13
Pneumococcal HUS

• 3 Metro Atlanta Childr Hosps, 94-96
• 7 pts, all lt24 m/o
• 2 meningitis, 5 pneumonia (3 empyema)
• All required dialysis (no CRF)
• 2 died
• 0.6 (4) of 618 children lt24 m/o w/invasive
  pneumococcal disease living in Metro Atlanta
• 23 of ALL HUS cases

Pediatrics 1998101699.
14
HUS

• HUS Pneumococcal vs Non-pneumococcal
• Occurred year-round (vs summer)
• Younger Median age 16 mos vs 5 yrs (plt.0001)
• More often required dialysis 100 vs 48 (p.03)
• Longer LOS Median 41 vs 12 days (p.008)

Pediatrics 1998101699.
15
Pneumococcal HUS

• 4 US Childrens Hosp, 90-99
• 12 pts
• 2 meningitis, 9 pneumonia (8 w/empyema), 1 both
• Mean age 22 mos (4-62 mos)
• 9 dialysed (2 CRF)
• 0 died

Pediatrics 2002110371.
16
HUS

• Pneumococcal vs Non-pneumococcal
• Occurred in winter (vs summer)
• Younger Mean age 22 vs 49 mos (p.005)
• More often required dialysis 75 vs 59 (pNS)
• Longer LOS Mean 33.2 vs 16.1 days (p.004)

Pediatrics 2002110371.
17
US Pediatric Multicenter Pneumococcal
Surveillance Group

• Brenner Childrens Hosp
• Childrens Memorial Hosp, Chicago
• Childrens Hosp, Columbus
• Texas Childrens Hosp, Houston
• Arkansas Childrens Hosp, Little Rock
• Childrens Hosp, Los Angeles
• Childrens Hosp, Pittsburgh
• Childrens Hosp, San Diego

18
USPMPSG

• Total cases of invasive pneumococcal disease
• 9/1/1993 to 6/7/06 n4109
• Cases of HUS 10/41090.24
• 2 meningitis, 8 pneumonia
• 8 Serotyped (Vaccine 4,6B,9V,14,18C,19F,23F)
• 3- 3
• 1- 7
• 2- 14
• 2- 19A

19
Brenner Childrens Hospital- Invasive
Pneumococcal Disease
Conj. Vaccine Licensed Feb, 2000
70
60
50
19
Isolates
40
Not penicillin-susceptible
13
30
20
10
0
Year
20
Pleural Empyema

• Primary Childr Med Ctr, Utah, 93-99
• Incidence (for pop lt19 y/o) increased
• 1994 1/100,000 1999 5/100,000 (p.0002)
• Pneumococcal isolates in empyema vs. pneumonia
• Serotype 1 50 vs. 7 (p.007)
• Pen non-susc 16 vs 48 (p.002)

Byington. Clin Infect Dis 200234434.
21
Pneumonia
Empyema Empyema incidence
No. of Cases
Incidence/100,000 population aged lt19 years
Year
Byington. Clin Infect Dis 200234434.
22
Pleural Empyema

• Primary Childr Med Ctr, Utah, 96-05
• Pre-vacc (96-00) vs Post-vacc (01-05)
• Mean empyema cases/yr 38 vs 72 (p.006)
• Total pneumoc cases 24 vs 50 (p.008)
• Serotype 1 most common (46 and 34)
• Serotype 3 0 vs 10 cases (p.025)
• No effect due to antibiotic resistance
• 4/74 (5.4) w/pneumococcal empyema had HUS

Byington. Pediatr Infect Dis J 200625250.
23
Cases of empyema in children treated at IHC ( )
and PCMC ( ). Byington, Pediatr Infect Dis J
200625250.
24
Pulmonary Manifestations of Invasive CA-Staph
aureus Pediatric Infections

• Texas Childrens Hosp, 2001-2004
• 47/70 (67) CA-MRSA vs 12/43 (28) CA-MSSA had
  abnl pulmonary radiologic findings (plt.001).
• 51/80 (64) PVL vs 2/23 (9) PVL- had abnormal
  chest radiographs (plt.001).

Clin Infect Dis 200541583-90.
25
Clin Infect Dis 200541583-90.
26
Venous Thrombosis in CA-Staph aureus
Osteomyelitis

• Texas Childrens Hospital, 1999-2004
• 9 pts w/VT all adjacent to site of osteomyelitis
• 4 with septic pulmonary emboli 3 given IVC
  filters
• 7 MRSA (all PVL) 2 MSSA
• 7/116 (6) of pts w/CA-MRSA acute hematogenous
  osteomyelitis

Pediatrics 20061171673-9