Age: 18.0
Sex: M
Vaccine: MEN, PPV
Symptoms: Purpura, Pyrexia, Rash, Respiratory rate decreased, Rhinorrhoea
Clinical narrative: It was reported in a published article, that an 18 year old male pt, enlisted in the military, on no medications, without any significant past medical or surgical history, was vaccinated one month prior to admission (date not specified) with a dose of pneumococcal 23v polysaccharide vaccine (manufacturer unknown)(Lot # not reported). Concomitant therapy included meningococcal vaccine (unspecified) which was also given one month prior to admission. On admission to the hospital the pt presented with a three week history of rhinorrhea that progressed to fevers, a dry cough, and chills over the four days before admission. The pt noted a rash that began on both ankles that spread proximally to the pt's distal thighs two days before admission. The rash was not painful or pruritic. The pt denied headache, confusion, dyspnea, or chest pain. There was no exposure to ticks or animals. Examination revealed: temperature 38.2 degrees C; pulse 78 beats per minute; blood pressure 110/59mmHg; respiratory rate 20 breaths per minute and oxygen saturation 99%. He was ill-appearing.  His lungs had decreased breath sounds in the left lower lobe with accompanying crackles. Skin examination showed a nonblanching, nonpalpable, purpuric rash extending from both ankles to his thighs. Lab evaluation revealed: white blood cell count 15,100 cells/mm^3; hemoglobin 13.2 mg/dL; platelets 263,000 and normal chemistry panel. Liver function tests were normal except for an albumin of 2.6mg/dL. International Normalized Ratio was elevated at 1.4 with a prothrombin time of 13.8 seconds, and partial thromboplastin time of 34.3 seconds, a disseminated intravascular coagulation panel was negative and chest radiograph demonstrated a left lower lobe infiltrate without effusion of adenopathy. The elevated INR resolved over 48 hours without any specific therapy. The pt was treated with ceftriaxone and levoflaxcin for community required pneumonia.  The pt continued to have temperatures of 39.1 degrees Celsius for the first 36 hours and then became afebrile. Further work up for the etiology of the pt's illness included two sets of blood cultures; Chlamydia pneumoniae and Mycoplasma pneumoniae IgM and IgG serologies; viral cultures for adenovirus; respiratory syncytial virus; influenzae; and parainfluenzae (Rhinoprobe); and antistreptolysin O titer and throat culture for group A streptococcus and N. meningitidis. All of these tests were negative. A polymerase chain reaction for N. meningitidis on acute serum was negative. Urine pneumococcal antigen (Binax NOW) was positive. The pt was discharged after four days of hospitalization to complete a 10 day course of levofloxacin.  Ten days after discharge, his cough and purpuric rash had "completely resolved" and the pt had returned to military training. This case described benign purpura occurring with an uncomplicated community-acquired pneumonia due to S. pneumoniae.  The authors noted that they established the diagnosis using the Binax NOW antigen test, which identifies the S. pneumoniae C polysaccharide antigen in urine and has a specificity of 97%. The authors acknowledged that their diagnosis was presumptive since cultures from sterile sites (ie blood) were negative; and extensive work up for other etiologies was also negative. It was also noted that this case had nonpalpable purpura in the absence of disseminated intravascular coagulation or septic shock.  It was noted that S. pneumonia should be considered among pt's presenting with purpura and pneumonia, sepsis, or meningitis, regardless of vaccination status.  Additional information is not expected. A copy of the published article is attached as further documentation of the pt's experience.