Age: 2.5
Sex: F
Vaccine: DPP, HIBV
Symptoms: Lethargy, Meningitis, Pyrexia, Rash, Sepsis
Clinical narrative: A physician reported that a 12 month old female received an injection of Hib-Titer on 12/23/98. On 7/9/00, at the age of 31 months, the child was dx'd with meningitis and septicemia. She was hospitalized and treated with unspecified antibiotics. The child recovered and was discharged on 9/17/00. *Follow-up report on 10/7/02: A report from manufacturer "An MD reported that a 12-mt-old received an injection of Hib-Titer on 12/23/98. On 7/9/00 at the age of 31 mts, the child was diagnosed w/meningitis and septicemia. She was hospitalized and treated w/unspecified antibiotics. The child recovered and was discharged on 7/17/00." From follow-up faxed correspondence received on 7/16/01 it was reported that a KUB(?) was ordered which was normal. The upper GI was done and showed narrowing of the 2nd portion of the duodenum. A barium enema was also done which was also negative. Alylase and lipase were drawn which were both w/in normal limits. Blood culture had grown gram negative bacilli. Due to worsening clinical condition and growth of gram-negative hecilli from blood culture, the PT was started on ampicillin and gentamicin. The PT had a lumbar puncture done w/Gram stain showed rare gram-negative bacilli and many PMNs w/white blood cell count of 871 w/61 segs, 25 bands, 1 lymph, 13 monos, 663 red blood cells, 118 CF protein and 27 glucose. As a result, PT was thought to have H flu type B meningitis. The PT was continued on ampicillin and gentamicin and restarted on Recephin. Ampicillin and gentamicin were discontinued and PT was kept on Rocephin 1.2 gm every 24 hrs for 10 days. A CT of the sinus was done on July 11th, which showed chronic disease of the ethmoids and maxillary sinuses. The sinuses were considered to be the source of the infection. The IgG level was found to be deceased at 320, IgF level was 119, C3 level was 133, blood cultures grew back H flu type H, CSF cultures for bacteria had no growth to date. On 7/17, the PT was almost back to baseline was considered ready to be discharged. Principle diagnosis: H flu meningitis - chronic, chronic sinusitis. Follow up #2 received on 9/19/02 from literature report: The PT is a 30 mt old, previously healthy female child who presented to the Emergency Dept w/the acute onset of fever to 102 deg F that evening. Her mother noted some mild, clear rhinorrhea and sneezing for several days. Shortly after the onset of fever, she vomitted several times and complained of some headache. As the evening progressed, her appetite and fluid intake declined. The PT received a completed primary series of vaccinations at the local health dept w/out adverse reactions. She received a tetanus toxoid conjugated Hib vaccine at 2 mts of age and a diphtheria cross-reacting material protein conjugate at 4, 6 and 12 mts. She did not receive conjugate pneumococcal or rotavirus vaccines. The child seemed weak, febrile to 39.4 deg C, and tachycardic to 150 beats/min w/a stable blood pressure of 106/54 mm Hg. She weighed 12 kg (25th percentile). Head and neck exam was notable for dull tympanic membranes and clear rhinorrhea. Mucous membranes were dry. There was no nuchal rigidity or cervican edenopathy. Lungs were clear. Cardiovascular exam revealed tachycardia w/a 2/6 systolic murmur at the left, upper sternal border and good peripheral pulses and perfusion. Abdomen was soft, nontender, and nondistended w/out organomegaly nor peritoneal signs. Multiple small pustules were noted on the inner thighs, but no other rash was apparent. Neurologically, the child was normal and responsive to commands. Complete blood cell count showed a white cell count of 2.200/mL w/33% neutrophilo. 13% bands, 50% lymphocytes, 3% metamyelocytes, and 1% atypical lymphocytes. The hemoglobin was 13.0 g/dL w/a hematocrit of 38.5%. Platelet count was 200,000/mL. A basic metabolic profile was notable for potassium of 3.2 mEq/L and blood urea nitrogen of 13 mg/dL. Urinalysis was unremarkable. Blood and urine cultures were obtained. In the Emergency Dept, the PT received intravenous fluids and 500 mg ceftriaxone. Although more active after hydration, she continued to vomit and was admitted. W/in 12 hrs, she became more lethargic, developed meningeal signs, and was transferred to the pediatric intensive care unit. Her initial blood culture grew pleomorphic Gram-negative coccobacilli. Lumbar puncture yielded slightly hary cerebrospinal fluid with glucose of 27 mg/dL (normal 45 to 75 mg/dL), protein of 118 mg/dL (normal 14 - 45 mg/dL0, 653 REC/mL, and 871 WBC/mL. The microbiology lab later identified Hemophilus influenza type b (Hib) from the blood culture. Cerebrospinal fluid culture was sterile, but latex agglutination to Hib was positive. Lab evaluation revealed normal IgA, IgM, and IgE levels. Total IgG was low-normal w/depressed IgG and IgG4 levels. Although C3 and C4 levels were normal, the PT's CH50 was below the level of detection on 2 occasions. This case is closed.