Sex: F
Vaccine: PPV
Symptoms: Death, Vaccination failure
Clinical narrative: Information has been received from a published article. Abstract: Introduction: Invasive Streptococcus pneumoniae disease (IPD) carries a high risk of death, approximately 15% to 20% in pneumonia, 40% in meningitis and 10% to 15% in septicemia. The occurrence of 2 or more IPD (recurrent) in the same individual is uncommon. The authors investigated the clinical features of patients with recurrent IPD to assess whether they possessed risk factors that increased their likelihood of recurrent IPD. Methods: Between 1983 and 2010, the authors identified 27 patients with recurrent IPD during inpatient surveillance of 889 patients with IPD in their city, by recovery of pneumococci from otherwise sterile sites. Serotype/serogroup (ST/SG) was determined by capsular swelling and the penicillin MIC by E-strip. Clinical data were abstracted from hospital charts. Results: Sixteen (59%) of 27 patients were 65 years and older at first IPD, males predominated (67%), two-thirds had pneumonia and 21 (78%) had the same clinical diagnosis at both IPD. Four (80%) of 5 patients with the same ST experienced their second IPD 1 to 6 months apart, unlike most patients with discordant ST/SGs (P = 0.047). Eighty-four percent of ST/SGs were included in the PNEUMOVAX 23 and occurred as often during the first and second IPD. Twenty (77%) of 26 adults suffered from comorbid diseases placing them at high risk of IPD, including multiple myeloma, HIV/AIDS, neoplasia of hematological origin and sickle cell disease. Conclusions: Recurrent IPD occurred uncommonly. Comorbid conditions including multiple myeloma and immunosuppressive/immunodeficient conditions, chronic alcoholism and splenectomy represented unique risk factors for recurrent IPD but did not predict recurrences. Results: Continuous surveillance of IPD among inpatients residing in the city, and environs from 1983 to 2010 identified 989 individuals with IPD, 813 adults and 176 children, and recurrent IPD was detected in 26 adults (a total of 28 episodes) and 1 child, for recurrence rates of 3.4% and 0.6%, respectively. Sixteen (61.5%) of 26 adults were 65 years or older when they had their first IPD. Males accounted for 18 (66.7%) of the patients. All 5 adults who died during their second IPD were 65 years or older when they experienced their first IPD. However, the case fatality rate (CFR) of the age group 65 years and older was not significantly different from the nil CFR of the age group 30 to 64 years (P =0.12), likely due to the small Ns. Three females (33.3%) and 2 males (13.3%) died, also not a significant difference (P=0.29). Of the 5 patients who died, 3 had pneumonia at their second IPD, 1 had septicemia and 1 had meningitis, the second of 2 meningitis illnesses. Only 5 (19.2%) of 26 adults received PPV23 before their second IPD and none of them died. Three of these vaccinated adults suffered from multiple myeloma. The other adult with multiple myeloma did not receive PPV23. Three adults received PPV23 during or after their second IPD. No data were available on vaccine administration for the other 18 adults including 1 male with multiple myeloma. Although, no data were available on vaccine administration for the only child with recurrent IPD, he was born after routine immunization of infants and children with PCV7 was initiated and was aged 1 year at the first IPD and it seemed likely that he had received at least 1 dose of PCV7. The time interval between consecutive episodes of IPD varied from 1 month to 15 years. Of 10 consecutive episodes that occurred 1 to 12 months apart, the second IPD of 4 (80%) of 5 with the same ST/SG and 6 (28.6%) of 21 with different ST/SG occurred within 12 months of the first IPD (P =0.055). Three patients did not have the isolate from their second IPD available for serotyping. The occurrence of 3 consecutive IPD with the same ST/SG each more than 1 month apart suggests that these recurrent IPD were reinfections, as opposed to relapses. Twenty-two (75.9%) of 29 consecutive episodes of IPD showed the same diagnosis each episode. Recurrent pneumonia/pneumonia episodes accounted for slightly more than one-half of consecutive episodes and occurred across the spectrum of time intervals from 1 month to 15 years apart. By comparison, the few recurrent septicemia/septicemia episodes occurred 1 to 12 months apart and the 2 meningitis/meningitis episodes occurred 7 or more years apart. Overall, 45 (84.9%) of 53 ST/SGs recovered from patients with recurrent IPD were included in PPV23, with about the same proportion of vaccine ST/SGs in the first, second and third episodes, namely 85.2%, 83.3% and 100%, respectively (P=1.00). Only 5 ST/SGs not included in PPV23 were recovered, totaling 8 isolates. Of the 50 isolates tested for penicillin susceptibility during all recurrent IPD, 9 (18.0%) were intermediate, including 2 from non-PPV23 ST/SGs, and 5 (10.0%) were resistant to penicillin. Three (33.3%) of 9 patients with intermediate or resistant ST/SGs died during their second or third IPD compared with 2 (11.8%) deaths among the 17 patients with penicillin-susceptible ST/SGs (P =0.30). Immunosuppressive/immunodeficient comorbid diseases occurred in 21 (80.8%) of 26 adults, 10 (100%) of 10 adults in the 30 to 64 year age group and 11 (68.8%) of 16 adults in the 65 years and older age group (P =0.12). Four patients had multiple myeloma, 6 had solid cancers, 5 had lymphoma/leukemia, 1 had HIV, 4 had chronic renal disease and 5 had chronic alcoholism. Eight (80%) of 10 adults in the 30 to 64 years age group and 9 (56.3%) of 16 adults in the 65 years and older age group had only 1 immunosuppressive/immunodeficient comorbid disease. Additionally, only 2 adults had a splenectomy before their first IPD. One adult in the 30 to 64 years age group sustained a gunshot wound to the head before his first of 2 meningitis illnesses, about 8 years apart, and he survived. Of the 5 patients who died, 3 had comorbid diseases that increased their risk of IPD, including 1 patient had alcoholism and chronic obstructive pulmonary disease (COPD); 1 patient had chronic renal failure, colon cancer, arteriosclerotic heart disease, COPD and hypertension and 1 patient had colon cancer. Nineteen (73.0%) of 26 adults had arteriosclerotic heart disease or COPD or hypertension, 14 (87.5%) of 16 adults in the 65 years and older age group and 5 (50.0%) of 10 adults in the 30 to 64 years old age group. Eight (50%) of 16 adults in the age group 65 years and older had 2 or all 3 of these comorbid diseases, as might be expected among a group of elderly adults. This report concerns a female patient among the three adults who received PNEUMOVAX 23 during or after their second IPD. The female patient was one of the 5 adults who died during their second IPD. She had experienced her first IPD when she was 65 years or older. The reporter commented as follows: Five patients with 6 episodes of IPD in our study each of whom had been immunized with PPV23 before their second IPD had ST/SGs included in PPV23 and can be considered as vaccine failures. Pre- and postvaccine antibody levels were not available for any patients. PPV23 has about 70% effectiveness in immunocompetent adults. However, 3 patients had multiple myeloma, 1 had chronic alcoholism and 1 was old when immunized and thus immunization with PPV23 likely failed to induce protective antibody levels accounting for their becoming infected with vaccine types. Nonetheless, adults at high risk need to be immunized with PPV23, according to the recommended schedule of immunizations, once when identified before the age of 65 years and again after 65 years, with at least a 5-year interval between doses of vaccine. Polyvalent conjugate pneumococcal vaccines under investigation in adults might provide an approach, either alone or in combination with PPV23, for improved protective efficacy in adults at high risk. This is one of several reports received from same source. Additional information has been requested.