ILLUSTRATIVE CASE

Pneumonia and Purulent Pericarditis Caused by Streptococcus pneumoniae An Uncommon Association in the Antibiotic Era Jose Carlos Flores-González, MD,* Fernando Rubio-Quiñones, PhD,* Arturo Hernández-González, PhD,* Moisés Rodríguez-González, MD,† Jose Antonio Blanca-García, MD,* Alfonso María Lechuga-Sancho, PhD,‡ and Sebastián Quintero-Otero, MD* Abstract: Bacterial pericarditis in children has become a rare entity in the modern antibiotic era. The most common pathogen is Staphylococcus aureus, being Streptococcus pneumoniae an exceptional cause. We present 2 children, who were diagnosed of pneumonia complicated with a pleural effusion that developed a purulent pericarditis with signs of cardiac tamponade. One of them had received 4 doses of the 7-valent conjugated pneumococcal vaccine. Systemic antibiotics and pericardial and pleural drainages were used. Pneumococcal antigens were positive in pleural and pericardial fluids in both cases, and S. pneumoniae was isolated from pleural effusion in one of them. Both children fully recovered, and none of them developed constrictive pericarditis, although 1 case presented a transient secondary left ventricular dysfunction. Routine immunization with 10and 13-valent vaccines including a wider range of serotypes should further decrease the already low incidence. Key Words: bacterial pericarditis, empyema, Streptococcus pneumoniae, pneumococcal pericarditis (Pediatr Emer Care 2014;30: 552–554)

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acterial pericarditis is an exceptional rare disease in childhood and is associated with significant morbidity and mortality.1–5 Current studies estimate a mortality rate of 20% to 30%; hence, a high index of clinical suspicion is essential for early diagnosis and treatment, in order to reduce this rate.6–8 A pericardiocentesis is required to obtain effusion samples for analysis and culture and also to evacuate the excess fluid in case of clinical cardiac tamponade; hence, this technique is both diagnostic and therapeutic. The most frequent microorganisms causing bacterial pericarditis are Staphylococcus aureus and Haemophilus influenzae,4–7 being Streptococcus pneumoniae very uncommon, especially in childhood.9 The 2 most common forms of clinical presentation and complication are cardiac tamponade and sepsis.3,7 Constrictive pericarditis is a rare complication, which tends to appear later in the course of the disease. Early pericardial drainage has been proposed as a preventive practice for this third complication.10 We present 2 cases of bacterial pericarditis due to a S. pneumoniae, causing pneumonia and pleural effusion, one of them in a previously immunized patient with 4 doses of the 7-valent conjugated antipneumococcal vaccine.

CASE 1 The patient was a 2-year-old boy, with unremarkable personal history, adequately immunized (including 4 doses of heptavalent From the *Pediatric Intensive Care Unit, †Pediatric Cardiology Unit, and ‡Pediatric Research, Hospital Universitario Puerta del Mar, Cádiz, Spain. Disclosure: The authors declare no conflict of interest. Reprints: Jose Carlos Flores-González, MD, Hospital Universitario Puerta del Mar, Unidad de Cuidados Intensivos Pediátricos (2ª Planta), Avda Ana de Viya 21, 11009 Cádiz, Spain (e‐mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161

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pneumococcal conjugated vaccine), who presented with a bilateral pneumonia. He was receiving medical care at a local hospital and antibiotic treatment with cefotaxime and clarithromycin. After 2 days, he was transferred to our pediatric intensive care unit (PICU) because of a sudden worsening of the respiratory status, attributed to a left, unilateral, parapneumonic pleural effusion. At admission, the patient had a septic appearance, with tachycardia (160 beats/min), blood pressure 95/55 mm Hg, and signs of respiratory distress, while maintaining normal saturation with oxygen support via nasal cannula. On physical examination, he showed hypoventilation and crackling in the left hemithorax, with a pericardial friction rub and palpable hepatomegaly. The laboratory tests revealed a hematocrit of 22%, severe thrombocytopenia (25,000/μL), coagulopathy (prothrombin activity 56%, cephalin time: 80 seconds, international normalized ratio: 1.4, fibrinogen: 743 mg/dL), hyponatremic dehydration (urea: 120 mg/dL, creatinine: 0.6 mg/dL, serum sodium: 127 mg/dL), and high procalcitonin (14.93 ng/mL). Chest radiograph showed a condensation on the base of the left side with pleural effusion and without signs of cardiomegaly. An ultrasound (US)–guided pleural drainage was placed, and 250 mL of purulent effusion suggesting empyema was drained initially. The sample culture was negative for any bacterial growth, but it was positive when tested for pneumococcal antigen. Local fibrinolytic therapy was initiated. An electrocardiogram and cardiac US scanning were performed because of the finding of the pericardial rub. The US showed a moderate pericardial effusion (14 mm) without signs of hemodynamic compromise (Fig. 1). Ibuprofen and colchicine were initiated as anti-inflammatory therapy. Follow-up cardiac US revealed a progressive increase of the effusion, reaching 24 mm with initial signs of heart tamponade. Pericardiocentesis was performed, draining 200 mL of purulent fluid (white blood cell count of 46,400/μL with 90% segmented cells, pH 6.9, and glucose: 3 mg/dL). As well as in the pleural fluid drained, microbacterial investigation in the pericardial effusion rendered no bacterial growth, but was positive for pneumococcal antigen (immunochromatographic test [BinaxNOW S. pneumoniae antigen test; Binax, Portland, Me]). Forty-eight hours later, cardiac US showed reduction of effusion to 10 mm, but fibrin was observed, so corticoid therapy was indicated. The patient presented no further complications and was discharged from the PICU to continue therapy at the pediatric board.

CASE 2 The patient was a 4-year-old boy receiving cefotaxime and cloxacillin for a unilateral pneumonia on the right side, who presented a sudden worsening of his respiratory status initially attributed to a pleural effusion, and was transferred to the PICU for drainage. The patient was in respiratory distress, although he maintained appropriate oxygen saturation. The pleural evacuation Pediatric Emergency Care • Volume 30, Number 8, August 2014

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Pediatric Emergency Care • Volume 30, Number 8, August 2014

FIGURE 1. Echocardiography showing a large pericardial effusion.

tube was inserted, rendering abundant purulent fluid suggestive of empyema. Thirty hours later, the patient presented progressive restlessness, increasing tachypnea (80–100 breaths/min), and tachycardia of 200 beats/min. The electrocardiogram showed an elevated ST segment and paradoxical pulse. We performed a cardiac US, revealing a severe pericardial effusion with signs of tamponade. Thus, a pericardiocentesis was performed. The patient responded favorably, but he did not recover completely and continued with persistent distress, pericardial effusion (17 mm at the back and 6 mm on the front side), and signs of tamponade in the control cardiac US (Fig. 2). A pericardial drainage tube was inserted, achieving then a significant clinical improvement. Drainage tube removal was possible after 4 days and was then discharged from our PICU. Penicillin-sensitive S. pneumoniae was identified in the culture of the pleural effusion. Pneumococcus antigens were identified in both pericardial and pleural fluids. Transient mild left ventricular dysfunction remained and required therapy with enalapril and furosemide for 6 months after the episode. Both children fully recovered, and none of them developed constrictive pericarditis.

Pneumonia and Pericarditis from S. pneumoniae

pericardial tamponade, requiring more aggressive treatment and monitoring than pericarditis of other etiologies. Pericardiocentesis and/or pericardial drainage are often necessary to confirm diagnosis and lead to rapid relief of symptoms and hemodynamic stabilization. In the presence of a purulent effusion, fibrin tracts, or the isolation of H. influenzae, some authors recommend performing a pericardial window or partial pericardiectomy, to avoid constrictive pericarditis development.3 The most common etiologic agent of bacterial pericarditis is S. aureus, S. pneumoniae being exceptional. The pathogenesis of pericarditis is controversial. In cases with pulmonary infection, some authors postulate the direct extension of bacteria from pleural empyema, whereas others suggest hematogenous dissemination with bacteremia and invasion of the pericardial cavity.3 The high rates of positive blood cultures for S. pneumoniae in published cases support this second possibility.11 Invasive disease by S. pneumoniae remains an important cause of pediatric morbidity and mortality worldwide.16,17 Since the introduction of heptavalent pneumococcal conjugate vaccine in the official immunization calendar of certain countries, the incidence of invasive infections caused by S. pneumoniae has decreased significantly, although there has been an increase of cases by serotypes not included in the vaccine.18 This situation urged the need for new vaccines with broader spectrum, resulting in the development of 10- and 13-valent conjugated vaccines, which are currently replacing the older heptavalent.19 In the literature reviewed, only 4 reports of pneumococcal pericarditis in children specified the serotype isolated (serotype 14 in 2 cases and 6A and 23F, respectively, in the other 2 cases). Since these 3 serotypes are included in the 13valent vaccine, it is foreseeable that their introduction into the immunization schedule will further reduce the low incidence of this rare but severe infection.

CONCLUSIONS

DISCUSSION

Despite the availability of pneumococcal vaccine and the widespread use of antibiotics, pericarditis by S. pneumoniae is still possible nowadays, so we must consider this complication in all children with pneumococcal pneumonia and empyema and a worsening clinical course. The use of antibiotics hampers the sensibility of bacterial culture in biological samples. In these cases, we may rely on the determination of pneumococcal antigen in pericardial fluid to support diagnosis.

Pericarditis by S. pneumoniae is a rare disease. To our knowledge, only 15 pediatric cases (66% in children

Pneumonia and purulent pericarditis caused by Streptococcus pneumoniae: an uncommon association in the antibiotic era.

Bacterial pericarditis in children has become a rare entity in the modern antibiotic era. The most common pathogen is Staphylococcus aureus, being Str...
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