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66―4205（ 17 ）Complications of adenotonsillectomy:
A case report of meningitis due to dual infection
with nontypeable Haemophilus influenzae andStreptococcus pneumoniae, and a prospective studyof the rate of postoperative bacteremia
JUNKO TANAKA1,2, TOMOMICHI KUROSAKI1, AKIKO SHIMADA3,YUMI KAMEYAMA3, TOSHIHIRO MITSUDA4, NARUHIKO ISHIWADA5
and YOICHI KOHNO2
1

Department of Pediatrics, Chiba Kaihin Municipal Hospital
Department of Pediatrics, Chiba University School of Medicine
3
Department of Otolaryngology, Chiba Kaihin Municipal Hospital
4
Department of Infection Prevention and Control,
Yokohama City University Hospital
5
Division of Control and Treatment of Infectious Diseases,
Chiba University Hospital
2(Received for publication July 9, 2013)

Case report Bacterial meningitis is a rare complication of adenotonsillectomy. We
present a case of meningitis due to nontypeable Haemophilus influenzae andStreptococcus pneumoniae after adenotonsillectomy. Pulsed-field gel electrophoresis
patterns indicated that the oral cavity was the source of +LQÀXHQ]DH and S. pneumoniae
LVRODWHGIURPWKHFHUHEURVSLQDOÀXLGBlood culture study

As bacteremia is thought to be one of the etiologies ofmeningitis, we prospectively investigated the rate of bacteremia as a complication ofDGHQRWRQVLOOHFWRP\2IWKHSDWLHQWVLQFOXGHGLQWKHVWXG\PHDQDJHRI¿YH\HDUVROG
11 (24%) had positive blood cultures during the operation. H. influenzae was thecommonest organism grown (seven cultures), three of seven produced ȕ-lactamase,followed by S. pneumoniae (one culture), H. parainfluenzae (one culture),
Peptostreptococcus micros (one culture), and Veillonella spp. (one culture). The bacteria
were composed of tonsil or adenoid surface cultures in eight of 11 patients (73%).
Conclusions We present a rare case of meningitis complicating a adenotonsillectomy
procedure, in a three years old boy. Meningitis is a rare complication of adenotonsillectomy, but bacteremia which may lead to meningitis occurs frequently, as the results.

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Introduction
Adenotonsillectomy is one of the most commonly performed procedures in children whowith recurrent tonsillopharyngitis, recurrent otitis media, persistent otitis media with effusion,nasal obstruction, and sleep apnea. The most common associated morbidities are nausea, vomiting, hemorrhage, pain, infection, and dehydration. However, serious infections including meningitis are rarely reported after adenotonsillectomy.
We present a case of meningitis due to dual infection with nontypeable +DHPRSKLOXVLQÀXHQzae and Streptococcus pneumoniae, complicating an adenotonsillectomy procedure in a three\HDUROGER\7RWKHEHVWRIRXUNQRZOHGJHWKLVLVWKH¿UVWFDVHRIVLPXOWDQHRXVPL[HGPHQLQJLWLV
after adenotonsillectomy.
Bacteremia is considered one of the etiologies of meningitis. Among children with occult
EDFWHUHPLDPHQLQJLWLVGHYHORSVLQWKUHHWRVL[SHUFHQWZKRDUHQRWWUHDWHGZLWKDQWLELRWLFVDWWKH
time of initial evaluation1). We prospectively investigated the rate of bacteremia as a complication
RIDGHQRWRQVLOOHFWRP\DQGLGHQWL¿HGWKHRUJDQLVPVFDXVLQJEDFWHUHPLD

Case Report
The patient was a three-year-old boy, weighing 16 kg, who underwent adenotonsillectomy
for obstructive symptoms with sleep apnea. Adenotonsillectomy was performed under general anesthesia with tracheal intubation. Retropharyngeal injection of lidocaine hydrochloride with epinephrine was used during the procedure. The patient had good anesthesia tolerance and no intraoperative problems. Swab cultures were taken from the resected tonsils and adenoid with sterilecotton.
Postoperatively, the patient was transferred to the otolaryngology ward and received routine
WUHDWPHQWZLWKLQWUDYHQRXVDPSLFLOOLQFOR[DFLOOLQ PJNJGD\HYHU\K VWDUWLQJDWPLQDIWHU
the operation. That evening he was noted to be lethargic and febrile, and the following day, thefever remained and he vomited in the morning. The wound was clean with little bleeding. Thirty¿YHKRXUVDIWHUWKHRSHUDWLRQKHGHYHORSHGJHQHUDOL]HGFRQYXOVLRQVZLWKORVVRIFRQVFLRXVQHVV
and nuchal rigidity. He was accordingly transferred to the pediatric ward.
Laboratory tests showed leukocytosis (16,400/mm3) with neutrophilia (95%) and elevated CUHDFWLYH SURWHLQ PJG/ ([DPLQDWLRQ RI WKH FHUHEURVSLQDO ÀXLG &6)  VKRZHG D OHXNRF\WH
concentration of 1700/ȝL with 85% neutrophils, increased protein (557 mg/dL) and undetectableglucose (plasma glucose: 159 mg/dL). Initial Gram stain of the CSF was negative. The CSF culture grew both nontypeable +LQÀXHQ]DH and S. pneumoniae. The minimum inhibitory concentration (MIC) against + LQÀXHQ]DH was 0.25 ȝg/mL for ampicillin (ABPC) and ≦0.03 ȝg/mL forAug. 2013

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66―4207（ 19 ）FHIRWD[LPH &7;  7KH 0,& DJDLQVW S.
Fig. 1. Pulsed-field gel electrophoresis(PFGE) patterns of Haemophilus inpneumoniae was 1.0 ȝg/mL for penicillin GÀXHQ]DH and Streptococcus pneumoniae
and 0.25 ȝJP/IRU&7;%ORRGFXOWXUHVJUHZ
chromosomal DNA isolated from theno organisms. However, cultures of the repatient, digested with SmaI restriction
enzyme.
sected tonsil swab grew+LQÀXHQ]DH Neisseria sp., and Į-hemolytic streptococci, while
cultures of the resected adenoid grew these organisms plus S. pneumoniae. Restriction fragment length polymorphism (RFLP) analysis
IRU EDFWHULDO LVRODWHV XVLQJ SXOVHG¿HOG JHOelectrophoresis (PFGE) was performed as previously reported2, 3). Sma, UHVWULFWLRQ HQ]\PH
was used for the analysis. PFGE patterns werethe same for + LQÀXHQ]DH isolated from theCSF, tonsil, and adenoid. They were also thesame for S. pneumoniae isolated from the CSF
and adenoid (Fig. 1).
Immunoglobulin concentrations were asfollows: IgG 715 mg/dL, IgA 67 mg/dL, IgM
94 mg/dL, C3 135 mg/dL, C4 29 mg/dL, andCH50 37.2 U/mL. IgG subclass levels werenormal. Cytometry of lymphocyte subpopula1–3: H. influenzae isolated from 1) tonsil, 2) adenoid
tions in the peripheral blood showed: CD2
and 3) cerebrospinal fluid.
67%, CD20 20%, CD4 36%, CD8 18%, CD3
4–5: S. pneumoniae isolated from 4) adenoid and 5)
cerebrospinal fluid.
57%, and CD4/CD8 ratio 2.0. Neutrophil
Lane M contained a molecular size marker (48.5-kb
SKDJRF\WRVLV IXQFWLRQ DQG VWHULOL]LQJ IXQFWLRQ
lambda DNA ladder).
PFGE patterns of H. influenzae isolated from thewere normal. Computed tomography showed
cerebrospinal fluid, tonsil, and adenoid were identical.
PFGE patterns of S. pneumoniae from theno evidence of a skull base defect.
cerebrospinal fluid and adenoid were also identical.
The patient was treated with a combinaWLRQ RI FHIWULD[RQH &75; PJNJGD\  SDQLSHQHPEHWDPLSURQ PJNJGD\  DQG GH[Dmethasone. After the bacterial pathogens were isolated, antimicrobial therapy was changed to&75;DORQH7KLVOHGWRDVLJQL¿FDQWLPSURYHPHQWLQWKHSDWLHQWʼVFRQGLWLRQDQGODERUDWRU\¿QGings. The child was treated with 10 days of intravenous antibiotics and recovered without hearing
loss or neurologic sequelae. He was discharged on the twentieth post-operative day.

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Material and methods
We performed a prospective study of 46 patients who were undergoing adenotonsillectomy
at the department of otolaryngology of Chiba Kaihin Municipal Hospital between NovemberDQG'HFHPEHU7KHLUDJHUDQJHGIURPWZRWR\HDUVZLWKDPHDQDJHRI¿YH\HDUV
None had cardiovascular risk factors. Informed consent was obtained from the parents. The operation was performed under general anesthesia with tracheal intubation, and after induction of anesthesia, retropharyngeal injection of lidocaine hydrochloride with epinephrine was performed.
)LUVW WKH DGHQRLGV ZHUH H[FLVHG DQG WKLV ZDV IROORZHG E\ WRQVLOOHFWRP\ %ORRG VDPSOHV ZHUH
FROOHFWHGIURPDSHULSKHUDOYHLQZKHQWKH¿UVWWRQVLOKDGEHHQUHPRYHG+DOIRIWKHEORRGVDPSOH
was inoculated into an aerobic blood culture bottle (BacT/ALERT® )$ ELR0pULHX[ ,QF 86$ and the other half into an anaerobic blood culture bottle (BacT/ALERT® FN).
All patients received no antibiotics before the operation and received ampicillin/sulbactam
sodium immediately after the samples were taken. Blood samples were incubated within theBacT/ALERT® 'V\VWHP ELR0pULHX[ DQGFRQWLQXRXVO\PRQLWRUHG6ZDEVZHUHWDNHQIURPWKH
resected tonsil and adenoid with sterile cotton. All of the samples were placed in sterile containers and taken to the microbiology laboratory immediately. They were inoculated onto media appropriate for the growth of aerobic and anaerobic bacteria and incubated. Bacteria from the samSOHVZHUHLGHQWL¿HGE\VWDQGDUGODERUDWRU\PHWKRGVDQGLQFXEDWLRQZDVWHUPLQDWHGDIWHUVHYHQ
days if no growth was found.

Results
7DEOHVXPPDUL]HVWKHEDFWHULRORJ\UHVXOWVRIWKHSRVLWLYHEORRGFXOWXUHV%DFWHULDOSURGXFtion was observed in eleven of 46 patients (24%). +LQÀXHQ]DHwas the most common organism
grown (seven cultures); three of these seven isolated strains produced ȕ-lactamase. In eight of the
HOHYHQSDWLHQWVZLWKSRVLWLYHUHVXOWV  EDFWHULDLGHQWL¿HGLQEORRGZHUHDOVRJURZQIURPWRQsil or adenoid surface cultures. Of all 46 patients, eighteen had a fever after operation, andTable 1. Bacteriology of 11 positive bloodcultures.
four of these had bacteremia. There was no relationship between positive blood culture andfever. No patients developed severe complications and all were discharged without sequelae.

Discussion$UHYLHZRIWKHOLWHUDWXUHLGHQWL¿HGIURPDAug. 2013

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66―4209（ 21 ）FRPSXWHUL]HGVHDUFKUHYHDOHGUHSRUWVRIPHQLQJLWLVDIWHUWRQVLOOHFWRP\RUDGHQRLGHFWRP\3〜19).
Considering the number of these operations performed worldwide, meningitis appears to be a relatively rare complication.
7RWKHEHVWRIRXUNQRZOHGJHWKHSUHVHQWFDVHLVWKH¿UVWRIVLPXOWDQHRXVPL[HGPHQLQJLWLV
after adenotonsillectomy. PFGE indicated that the oral cavity was the source of both +LQÀXHQzae and S. pneumoniae isolated from the CSF. Meningitis developed in this patient despite prophylactic intravenous antibiotic treatment after the operation. It is possible that bacterial dissemiQDWLRQ VWDUWHG EHIRUH WKH DQWLELRWLFV ZHUH DGPLQLVWHUHG RU WKDW WKH$%3&FOR[DFLOOLQ JLYHQ ZDVLQVXI¿FLHQWIRUPHQLQJLWLVWUHDWPHQW7KLVDQWLELRWLFWUHDWPHQWFRXOGH[SODLQZK\WKHLQLWLDO*UDP
stain of the CSF was negative and the blood cultures failed to grow any bacteria.
Our prospective study demonstrated the high prevalence of bacteremia in patients after adenotonsillectomy; results were similar to those of previous studies of tonsillectomy, which havefound bacteremia in 22 to 40% of patients20〜22). In the present study, bacteremia was caused bybacteria from the tonsil or adenoid surface in eight of 11 patients (73%). Since the wounds remain open during the operation, adenotonsillectomy may lead to bacteremia as bacteria canspread hematogenously through within tissues and mucous membranes. Further, some have suggested that traction on the tonsil before dissection might facilitate microbial entry20). In any case,the high prevalence of bacteremia associated with tonsillectomy and adenoidectomy may be oneof the reasons that meningitis can occur as a complication.
ISAACSON et al.13) HQFRXQWHUHG WZR FDVHV RI PHQLQJLWLV DIWHU DGHQRLGHFWRP\ DQG WKH\ H[SORUHGDQRWKHUSRWHQWLDOH[SODQDWLRQRIWKHVHXQXVXDOFRPSOLFDWLRQV3UHVHQWLQJWKHDQDWRPLFQHWZRUN RI YHLQV RI WKH QDVRSKDU\QJHDO VXEPXFRVD DQG VXUURXQGLQJ VWUXFWXUHV WKH\ K\SRWKHVL]HGWKDWUHWURJUDGHYHQRXVÀRZRIEDFWHULDGXULQJUDSLGLQMHFWLRQRIOLGRFDLQHDQGHSLQHSKULQHLVWKH
most likely mechanism. This route of infection remains controversial, but it is interesting that inthe present case, we used injection of vasoconstrictors to decrease bleeding and improve visualL]DWLRQ+HQFHWKLVPLJKWEHDQRWKHUH[SODQDWLRQIRUWKLVUDUHFRPSOLFDWLRQ
Meningitis is a rare but life-threatening systemic complication of adenotonsillectomy, and its
VXFFHVVIXO PDQDJHPHQW GHSHQGV RQ HDUO\ FOLQLFDO VXVSLFLRQ +HQFH VXUJHRQV VKRXOG UHFRJQL]Hthis potential complication, since bacteremia occurs frequently after adenotonsillectomy, and thismay lead to meningitis.
Financial support
This work was supported by a research grant on the mechanism, epidemiology, prevention
and control of acute respiratory infections, Ministry of Health, Labour and Welfare.

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