Sex: M
Vaccine: PNC13
Symptoms: Hydrocephalus, Hypoxia, Infarction, Influenza A virus test positive, Intracranial venous sinus thrombosis
Clinical narrative: This is a literature report. The authors reported 4 reports, this is the 3rd of 4 reports and refers to case 2. A previously healthy 21-month-old boy presented to the emergency department with a 1-day history of fever to 103 F, emesis, cough, and lethargy. Rapid influenza testing was positive for influenza A, and oseltamivir was started. History was notable for day care attendance and multiple sick contacts. He was full immunized, including PCV13. The next morning, he had a brief seizure with eye deviation and generalized convulsions, and became obtunded. Simultaneously, blood culture grew gram-positive cocci in pairs and chains. He returned to the emergency department, where he had right-sided weakness, posturing, rightward eye deviation, and meningismus as well as further seizures requiring lorazepam and fosphenytoin. Laboratory testing were performed. Ceftriaxone and vancomycin were started at meningitic dosing. Cerebrospinal fluid grew S pneumonia serotype 15B, a non vaccine serotype. The large number of pneumococcal serotypes, and the possibility for even less invasive serotypes such as 15B to produce invasive disease as in patient 2, also provide support for alternative vaccination strategies that are not serotype-specific. MRI performed showed multifocal infarction. Imaging progressed to multifocal vasculitis, new ischemic strokes, and CSVT. Steroid therapy with dexamethasone 0.6 mg/kg per day was started on hospital (HD) 6 and continued through HD 19. Aspirin 81 mg (5 mg/kg per day) was started on HD 6 for secondary stroke prevention. 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. The patient remained seizure free after admission on phenytoin and then switched to levetiracetam. He was intermittently febrile for 7 days. He received 21 days of ceftriaxone and 5 days of oseltamivir; vancomycin was stopped after 48 hours when speciation and susceptibility results returned. Hydrocephalus developed with an acute decompression on HD 30 with apnea, desaturation, and emesis, for which an endoscopic ventricular drain was placed. He later underwent endoscopic third ventriculostomy with choroid plexus cauterization on HD 35. He spent a total of 42 days in the hospital. He passed a hearing test before discharge. Five months after discharge, at 27 months of age, the patient was meeting developmental milestones with a normal neurologic examination. There was no seizure recurrence and repeat EEG was normal, so levetiracetam was discontinued. This case of vaccinated child with pneumococcal meningitis due to non-PCV13 serotypes highlight its spectrum of cerebrovascular disease and morbidity. Pfizer is marketing authorization holder of Pneumococcal 13-val conj Vac in the report's country. This may be a duplicate report if another marketing authorization of Pneumococcal 13-val conj vac has submitted the same report to the regulatory authorities.