Age: 0.4
Sex: F
Vaccine: PNC13
Symptoms: Brudzinski's sign, C-reactive protein increased, CSF glucose decreased, CSF protein increased, CSF red blood cell count positive
Clinical narrative: The initial case was missing the following minimum criteria: unidentifiable patient. Upon receipt of follow-up information on 13Jul2016, this case now contains all required information to be considered valid. This is a literature report. The authors reported 4 reports, this is the 1st of 4 reports and refers to Case 1. A previously healthy, full-term 5-month-old girl presented to the emergency department with a 1-day history of fever to 103 F, emesis, poor feeding, and progressive lethargy. She had recently started day care. The patient had received her routine 2- and 4-month childhood vaccines on schedule, including PCV13. Initial examination revealed decreased responsiveness, rightward gaze preference, decreased movement of the left side, and positive Brudzinski sign. Laboratory testing were performed. Ceftriaxone and vancomycin were started at meningitic dosing. Cerebrospinal fluid grew Streptococcus pneumoniae serotype 33F, a non vaccine serotype. This patient had serotype 33F. Serogroup 33 has been noted to be increasing causes of invasive disease after the introduction of PCV7. MRI performed showed multifocal infarction. Imaging findings progressed over time to include additional ischemic and hemorrhagic strokes, arterial stenosis, and CSVT. Steroid therapy with methylprednisolone 1 mg/kg per day for 3 days was given on hospital day (HD) 3 and again on HD 8 out of concern for a vasculitis-like process. Anticoagulation was initiated on HD 5 given the progression of cerebral sinovenous thromboses on serial imaging, first with heparin drip then with low-molecular-weight heparin. In this case, clinical worsening prompted the initiation of steroid therapy in accordance with published recommendations for the treatment of central nervous system vasculitis, although the evidence supporting specific treatments of vasculitis especially secondary to infection is limited. For this patient, examination progressed to anisocoria, absent corneals, and absent oculocephalic reflex. On HD 3, seizures arose from the right posterior quadrant, progressing to status epilepticus requiring pentobarbital burst suppression for 12 days followed by levetiracetam, phenobarbital, and lacosamide. She remained afebrile after admission. She received 21 days of ceftriaxone; vancomycin was stopped after 48 hours when speciation and susceptibility results returned. She spent a total of 39 days in the hospital. She passed a hearing test before discharge, but aspirated on swallow study and eventually required a gastrostomy tube. Anticoagulation was discontinued after 3 months. The patient developed infantile spasms at 10 months of age. She continues to receive physical, speech, and occupational therapy. Her motor asymmetry has improved. At 17 months of age, she can crawl and babble. This case of vaccinated child with pneumococcal meningitis due to non-PCV13 serotypes highlight its spectrum of cerebrovascular disease and morbidity. Pfizer is a   [Due to memory limitations, the remainder of this text could not be compared.]  a marketing authorization holder of PCV13 in the reporter's country. This may be a duplicate report if another marketing authorization holder of PCV13 has submitted the same report to the regulatory authorities.