Sex: F
Vaccine: PNC15, PPV
Symptoms: Anticoagulant therapy, Antimicrobial susceptibility test resistant, Antimicrobial susceptibility test sensitive, Blood culture positive, CSF glucose decreased
Clinical narrative: multidrug-resistant Invasive pneumococcal disease (IPD) due to vaccine serotypes / Blood cultures grew S. pneumoniae; Although receiving pneumococcal vaccination, the patient developed multidrug-resistant invasive pneumococcal disease; Literature report:   This literature marketed report was received from the author as stated above, concerning a 38-year-old female patient with advanced human immunodeficiency virus (HIV) and one month prior to presentation history of left otitis media treated with amoxicillin sodium (+) clavulanate potassium (AUGMENTIN) and ciprofloxacin/corticosteroids ear drops.  On an unspecified date, she was vaccinated with pneumococcal vaccine (manufacturer unknown) (doses, route, frequency, lot # and expiry date were unknown).  On an unknown date, the patient presented with obtundation, fever and vomiting for 2 days. Left otalgia and otorrhea persisted prompting evaluation. She was febrile to 40C (104F) and tachycardic. On exam, she was minimally responsive with leftward eye deviation and purulent left ear drainage. Computerized tomography (CT) imaging showed opacification of the left external auditory canal, tympanic space, and mastoid with concern for venous sinus thrombosis. Magnetic Resonance Angiography / Magnetic Resonance Venography (MRA/MRV) confirmed left otomastoiditis and bilateral dural sinus thrombosis; Magnetic resonance imaging (MRI) brain suggested meningoencephalitis. Heparin drip and vancomycin, cefepime, ampicillin, and metronidazole were started. Empiric steroids were given and she was intubated and admitted to the intensive care unit (ICU). Lumbar puncture revealed cloudy cerebrospinal fluid (CSF) 10 225 white blood cells (WBC) (91% segs), glucose <10, and protein 348. Blood cultures grew Streptococcus (S.) pneumoniae and susceptibility testing revealed penicillin resistance with ceftriaxone minimum inhibitory concentration (MIC) 4 ug/ml; the isolate was also resistant to macrolides and Trimethoprim-sulfamethoxazole (TMP-SMX), but sensitive to vancomycin, linezolid, and fluoroquinolones. Antibiotics were narrowed to vancomycin and ceftriaxone for pneumococcal otomastoiditis complicated by bacterial meningitis. Left mastoidectomy with tympanostomy tube placement was done. HIV labs reflected long standing antiretroviral therapy (ART) noncompliance (CD4 31 and viral load 96 086); workup for other HIV associated opportunistic infections was negative. ART with bictegravir (+) emtricitabine (+) tenofovir alafenamide (BIKTARVY) was initiated and Pneumocystis Carinii Pneumonia (PJP) prophylaxis with TMP-SMX was started. After 2 weeks of vancomycin and ceftriaxone synergistic therapy, she was discharged on oral linezolid for additional 2 weeks and apixaban. At her 6-month clinic visit, left hearing loss persisted, but the left facial nerve palsy resolved. The patient had multidrug-resistant (MDR) pneumococcus defined as resistance to three or more antibiotic classes. Although the patient had received pneumococcal vaccination, Invasive pneumococcal disease (IPD) due to vaccine serotypes may occur and protective immunity post vaccination is reduced in acquired immune deficiency syndrome (AIDS).  Upon internal review, multidrug-resistant (MDR) invasive pneumococcal disease (IPD) was determined to be medically significant.  A copy of the published article is attached as further documentation of the patient's experience.