Sex: F
Vaccine: HIBV
Symptoms: Blood immunoglobulin G normal, Blood immunoglobulin M normal, Blood smear test normal, Brain stem auditory evoked response abnormal, CSF culture positive
Clinical narrative: Haemophilus influenzae meningitis; Viral upper respiratory tract infection; cough; Congestion; Fever; Vomiting; poor oral intake; decreased urine output; decreased activity level; Fussy; refused to sit up, and was not acting like herself; Increased work of breathing; alertness decreased; bilateral subdural empyema; Sensorineural hearing loss; Nuchal rigidity; adenovirus co-infection; Leukocytosis; central venous thrombosis; Labyrinthitis; This case was reported in a literature article and described the occurrence of hemophilus influenza meningitis in a 12-month-old female patient who received Hib UNK (Hib vaccine) for prophylaxis.   The patient's past medical history included otitis media acute. Previously administered products included Hib vaccination.   On an unknown date, the patient received Hib vaccine at an unknown dose. On an unknown date, less than a year after receiving Hib vaccine, the patient experienced hemophilus influenza meningitis (serious criteria hospitalization and GSK medically significant), viral upper respiratory tract infection (serious criteria hospitalization), cough (serious criteria hospitalization), respiratory tract congestion (serious criteria hospitalization), fever (serious criteria hospitalization), vomiting (serious criteria hospitalization), oral intake reduced (serious criteria hospitalization), urine output decreased (serious criteria hospitalization), decreased activity (serious criteria hospitalization), irritability (serious criteria hospitalization), behavior abnormal (serious criteria hospitalization), increased work of breathing (serious criteria hospitalization), alertness decreased (serious criteria GSK medically significant), subdural empyema (serious criteria GSK medically significant), sensorineural hearing loss (serious criteria GSK medically significant), nuchal rigidity, adenovirus infection, leukocytosis, venous thrombosis and labyrinthitis. The patient was treated with ceftriaxone, vancomycin, enoxaparin, antibiotics nos, antipyretics, nos (Antipyretics) and heparin (nos) (Heparin Infusion). On an unknown date, the outcome of the hemophilus influenza meningitis, oral intake reduced, irritability, behavior abnormal, increased work of breathing, sensorineural hearing loss, nuchal rigidity and adenovirus infection were unknown and the outcome of the viral upper respiratory tract infection, cough, respiratory tract congestion, fever, vomiting, urine output decreased, decreased activity, alertness decreased and leukocytosis were recovering/resolving and the outcome of the subdural empyema, venous thrombosis and labyrinthitis were recovered/resolved.   It was unknown if the reporter considered the hemophilus influenza meningitis, viral upper respiratory tract infection, cough, respiratory tract congestion, fever, vomiting, oral intake reduced, urine output decreased, decreased activity, irritability, behavior abnormal, increased work of breathing, alertness decreased, subdural empyema, sensorineural hearing loss, nuchal rigidity, adenovirus infection, leukocytosis, venous thrombosis and labyrinthitis to be related to Hib vaccine.  Additional information was provided as follows: This case was reported in a literature article and described the occurrence of haemophilus Influenza Type F Meningitis infection in a 12-month-old female patient of who was vaccinated with unspecified haemophilus influenzae type B (Hib) conjugate vaccine (manufacturer unknown) for prophylaxis.  The patient was previously healthy and was immunocompetent. The patient had the recent history of bilateral acute otitis media. No information on patient's medical or family history or concomitant condition was provided. On unspecified date, the patient was fully immunized with the unspecified haemophilus influenzae type B (Hib) conjugate vaccine (administration route and site unspecified, dosage unknown; batch number not provided). The age of vaccination was not provided. On an unspecified date, unknown period after vaccination, the patient developed cough, congestion, vomiting, and fever with poor oral intake and decreased urine output leading to first presentation at the emergency department. The patient showed improvement in activity level during the evaluation and was discharged home with a clinical diagnosis of a viral upper respiratory infection. Over the next four days, she had normal oral intake and urine output, but continued to have decreased activity level, congestion, mild cough, and fever despite scheduled antipyretics. The patient's parents noted that she was fussy, refused to sit up, and was not acting like herself. The patient developed increased work of breathing which prompted a second presentation to the emergency department. The patient was noted to be afebrile, awake, and alert but was significantly irritable with nuchal rigidity. Cranial imaging was not performed, but lumbar puncture revealed cloudy cerebrospinal fluid (CSF) concerning for bacterial meningitis. Initial CSF studies revealed: Glucose less than 4 mg/dL, protein 107 mg/dL, Leukocyte count 4,063 cells/cmm, and 89% neutrophils. She was empirically started on ceftriaxone and vancomycin and admitted for bacterial meningitis. CSF cultures eventually grew H. influenzae type f sensitive to ceftriaxone. Respiratory swab revealed adenovirus co-infection. The patient improved clinically in terms of alertness and activity level with down-trending leukocytosis and inflammatory markers but continued to spike fevers despite scheduled antipyretics and was noted to be tugging at her right ear. A magnetic resonance imaging (MRI) scan was obtained, which showed bilateral subdural empyema (SDE), central venous thrombosis, and enhancement of inner ears Right-sided burr-hole craniotomy was performed to drain the empyema for further source control; cultures of the purulent drainage were negative. The central venous thrombosis was treated with heparin infusion with transition to enoxaparin. Repeat MRI showed improving empyema (MRI showing resolution of bilateral subdural empyemas , but persistent labyrinthitis (Axial, post-contrast T1-weighted MRI displaying persistent labyrinthitis. Given the severity of her presentation, immunological studies included H. Influenzae B IgG 3.37 (more than or equal 0.15 mg/L); Total IgG 569 (280-1,030 mg/dL); Total IgA 33 (15-160 mg/dL); Total IgM 108 (35-140 mg/dL); Total Complement, CH50 73 (41-95 U/mL); Total Complement, AH50 66 ( more than or equal 46%); Tetanus IgG 0.30 (more than or equal 0.01 IU/mL) and Diphtheria IgG 0.08 (more than or equal 0.01 IU/mL) were performed and confirmed she was immunocompetent and had responded to her previous Hib vaccination. To assess for functional asplenia, a blood smear was performed and showed no Howell-Jolly bodies. Intravenous antibiotics were administered for four weeks and discontinued based on resolution of findings previously seen on MRI. Enoxaparin was administered for a total of six weeks. Auditory Brainstem Response testing performed during repeat MRI showed profound bilateral sensorineural hearing loss, requiring bilateral cochlear implants and tympanostomy tubes. This case has been considered as serious due to hospitalization. The outcome of the event was not provided.  The author commented, "In the meantime, this report contribute to the understanding of this decreasingly rare disease, thereby helping in management of these patients. They report a case of a 12-month-old, immunocompetent female that presented with Haemophilus influenza type f meningitis and a clinical course complicated by bilateral subdural empyemas, central venous thrombosis, and bilateral sensorineural hearing loss. Her initial presentation was significant for viral infection positive for adenovirus and recent history of bilateral acute otitis media which may have predisposed her to colonization and infection." The author concluded "Despite the success of vaccination in reducing invasive disease, cases of H. influenza meningitis continue to occur via less common encapsulated serotypes with unknown complications making the management and treatment of these infections more difficult for practitioners. Continued reporting of these non-type b cases will aid in achieving further understanding and appropriate management." The article corresponding to this case is not available for submission due to copyright restriction.  Lab Comments: Lab test done on unknown date. Lumbar puncture revealed cloudy cerebrospinal fluid (CSF) concerning for bacterial meningitis. A magnetic resonance imaging (MRI) scan was obtained, which showed bilateral subdural empyema (SDE), central venous thrombosis, and enhancement of inner ears Right-sided. Repeat MRI showed improving empyema (MRI showing resolution of bilateral subdural empyemas , but persistent labyrinthitis (Axial, post-contrast T1-weighted MRI displaying persistent labyrinthitis. Auditory Brainstem Response testing performed during repeat MRI showed profound bilateral sensorineural hearing loss.