Age: 1.0
Sex: F
Vaccine: HIBV
Symptoms: Irritability, Meningitis bacterial, Meningitis haemophilus, Musculoskeletal stiffness, Nuclear magnetic resonance imaging abnormal
Clinical narrative: This case was reported in a literature article and described the occurrence of bacterial meningitis due to Haemophilus influenzae type E (Hie) in a 9-year-old female subject who was vaccinated with Hib vaccine (manufacturer unspecified). Historic vaccination included Hib vaccine; given at 2, 4, 6 month of age (manufacturers, batch numbers, doses and injection sites unknown). The authors report that the subject was healthy before the event. Investigations performed during the event confirmed that the subject and her younger sibling were up to date with their immunisations, including the Hib conjugate vaccine. No further information on her medical, family history or concurrent medication was available. When she was 12 month old, the subject received 4th dose of Hib vaccine (unknown route and injection site, lot number not provided). On 24 October 2011, 8 years after vaccination with Hib vaccine, the subject presented to a paediatric office with a 2-week history of upper respiratory tract infection symptoms, including a non-productive cough and negative strep throat culture, fever up to 39.4 Deg. C, headache, stiff neck, irritability but no rash. The presumed diagnosis at the time was bacterial meningitis. The subject was treated initially with a single dose of intramuscular ceftriaxone (50 mg/kg) and she was transferred to a local emergency department where a head computed tomography scan with contrast performed suggested acute or chronic pansinusitis; the subsequent magnetic resonance imaging of the brain with contrast also demonstrated pansinusitis with no evidence of intracranial abscess or tracking from the sinuses. Based on these finding the differential diagnosis at the time was bacterial meningitis due to invasive H. influenzae and/or meningococcal disease. The subject was treated with intravenous ceftriaxone, GENTAMYCIN and vancomycin. No steroids were administered in view of the unclear gram stain results and low suspicion for Hib meningitis. The subject was hospitalised to the paediatric intensive care unit. Since meningococcal disease could not be ruled out, the local health department was contacted to initiate an investigation. On 26 October 2011, the subject's condition had improved significantly so she was transferred to a regular paediatric ward. Her antibiotic regimen was switched to ceftriaxone alone at that time as the initial negative cerebrospinal fluid culture following only a single dose of ceftriaxone suggested that the organism was susceptible to that antibiotic. Staff from the regional department of public health interviewed the subject's mother at this point to determine any potential exposure and the need for post exposure prophylaxis for bacterial meningitis due to invasive Haemophilus influenzae and/or meningococcal disease. The subject's family received prescriptions for post exposure prophylaxis; ciprofloxacin for the parents and rifampin for the younger sibling. On 27 October 2011, Haemophilus influenzae type E was identified from the subject's cerebrospinal fluid culture. The final diagnosis was bacterial meningitis due to invasive Haemophilus influenzae type E. On 30 October 2011, the subject was discharged home due to her recovery. On 02 November 2011, during a follow up with her paediatrician, the subject still had some mild headaches, but she had no neurological deficits and was doing well. Author's conclusion: "For the post-Hib conjugated vaccine era, we are not aware of any other published cases of meningitis due to Hie among previously healthy school-aged children in this country; however, agency reported Hie meningitis amongst two previously healthy children in two other countries."