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Pneumococcal septicemia and meningitis in the neonate
April 1975
The Journal of P E D I A T R I C S
593
Pneumococcal septicemia and meningitis in the neonate Philip
G. Rhodes, M.D.,* Virgil F. Burry, M.D., Robert T. Hall, M.D., and
Robert C o x , M . D . , Kansas City, Mo.
with Streptococcuspneumoniae a r e u n c o m in the neonate. While group B streptococcal infections are appearing with increasing frequency,~-4 few reports of pneumococcal disease in the newborn infant have been published. Our experience indicates a need for increased awareness of this infection. In this report we describe five cases of neonatal septicemia and/or meningitis attributed to Streptococcus pneumoniae.
I N F E CT I O N S mon
PATIENTS
AND METHODS
The charts of all infants less than 28 days of age (during the period 1969-1973) who had positive cultures of e i t h e r b l o o d or c e r e b r o s p i n a l fluid for Streptococcus pneumoniae were reviewed. Four patients were identified. A n additional infant was reported to us by a physician in a nearby community. F o u r of the five infections occurred within the last two years. All organisms were identified by utilizing standard m e d i a on the basis o f colonial m o r p h o l o g y , a l p h a hemolysis, G r a m stain, and sensitivity to the optichin disc. Sheep blood and chocolate agars were used for initial isolation o f the o r g a n i s m s . Blood c u l t u r e s were placed in brain-heart infusion and thioglycollate media. Serotyping was not performed. N o n e of the organisms had the characteristics of the group B streptococcus. RESULTS Table I summarizes the clinical course, laboratory data, and outcome. Three infants presented with symptoms at less than 4 days of age. Clinically, the disease was severe and manifest by respiratory distress, cyanosis, temperature instability, and shock. Each of the *Reprint address: Children "sMercy Hospital, 24th and Gillham, Kansas C2ty, Mo. 64108.
three patients died within 36 hours after admission. A rapidly progressive p n e u m o n i a was seen radiographically and was also present at autopsy. A leukopenia was p r e s e n t in each i n f a n t and the p o l y m o r p h o n u c l e a r leukocyte response was deficient. Cultures of the vaginal cervix were obtained from two mothers and both were positive for Streptococcus pneumoniae. In addition to three newborn infants with early onset of illness, two other neonates presented with less apparent symptoms at 14 and 20 days of age, respectively. The disease was manifest by fever, lethargy, and irritability. One of the two patients presented with a temperature of 101~ The cerebrospinal fluid contained numerous cells and g r a m - p o s i t i v e , l a n c e t - s h a p e d o r g a n i s m s b u t t h e cultures were negative. The blood culture, however, was positive for Streptococcus pneumoniae under anaerobic conditions. Each of the patients with disease of late o n s e t r e c o v e r e d following t r e a t m e n t . N e i t h e r i n f a n t had the leukopenia seen in the early onset type of illness. DISCUSSION Meningitis or septicemia in 14 neonates has been diagnosed at our institution in the past two years. Three of these were due to Streptococcus pneumoniae and four were d u e to group B b e t a h e m o l y t i c s t r e p t o c o c c u s . A n o t h e r infant was reported to us from a nearby community during the past year. A fifth case occurred five years ago in our hospital. All other infections were caused by gram-negative organisms. In reviewing our cases, we were impressed by what appeared to be an increase in the incidence of Streptococcus pneumoniae infection. T h e r e also was a s t r i k i n g similarity in the pneumococcal infection and group B streptococcal illness currently being recognized in the neonate.
Vol. 86, No. 4, pp. 593-595
594
Rhodes et al.
The Journal of Pediatrics April 1975
Table I. Neonatal pneumococcal sepsis
Patient 3 days, female, white, 40 wks' gestation
1 day, male, white, 37 wks' gestation
Presenting symptoms
Peripheral white blood count (mm 3)
Respiratory distress, abdominal distention, tachycardia, temp (101.4~ Respiratory distress, temperature (97.4~
1,800; no pmn's seen; decreased platelets
2,200; 9% pmn's
1 day, female, white, 32 wks' gestation
Respiratory distress, temperature not recorded
2,200; 2% pmn's
20 days, male, black, 40 wks' gestation
Irritability, abdominal distention, watery stool, temperature (102.4~ Irritability, anorexia, temperature (102~
10,300; 37% pmn's
Cemb~mal fluM* 4 wbc's 0 pmn's, 4 lymphocytes, glucose 19, protein 35, positive culture, blood glucose 40 28 wbc's,12 pmn's, 16 lymphocytes glucose 82, protein 270, negative culture, blood glucose not done 1 wbc, 1 lymphocyte, glucose 44, protein 166, negative culture, k'-'~d glucose not
Positive pneumocoecal cultures
OuWome
Blood, nose, CSF
Pneumonia, died at 36 hours
Blood, nose, maternal cervix
Pneumonia, died at 15 hours
CSF,lungs (postmortem), maternal cervix
Pneumonia, died at 12 hours
Blood, throat
Recovered
Blood (anaerobic)
Recovered
e
14 days, male, white, 40 wks' gestation
16,600; 52% pmn's
7 wbc's, 2 pmn's, 5 lymphocytes glucose 75, protein 45, negative culture, blood glucose 94 645 wbc's 45 pmn's, 600 lymphocytes, glucose 32, protein 29, positive smear, negative culture, blood glucose 58
*Italic n u m b e r g i v e n in mg/dl. A b b r e v i a t i o n s u s e d : p m n = p o l y m o p h o n u c l e a r , w b c = white blood ceils.
There are isolated case reports of neonatal pneumococcal infection. Several have been associated with endocervical disease in the mother. 5,6 A recent case report described meningitis in the mother and in her infant.7A case report and review by Hogg and Bradley 8 reports 27 cases. A comprehensive review of neonatal meningitis by Fosson and Fine 9 lists 27 Streptococcus pneumoniae infectiOns as part of 457 cases of neonatal meningitis summarized from the literature. Neither of these reports alluded to the similarity to group B infection. We have no ready explanation for what appears to be an increase in the incidence of pneumococcal disease in the neonate at our hospital. We likewise have no explanation for the similar clinical course in the early onset of pneumococcal and group B beta hemolytic streptococcal infections. At the present time, both clinical entities carry the same poor prognosis.
Epidemiologically, it is i m p o r t a n t to d i f f e r e n t i a t e Streptococcus p n e u m o n i a e from alpha a n d beta streptococci. The morphologic colony appearance, hemolysis, and optichin disc can be helpful in the differentiation. One cannot rely on Gram stain with any degree of confidence. Although we did not do so, further differentiation by serologic means is important for closer epidemiologic surveillance. REFERENCES
1. Franciosi RA, Knostman JD, and Zimmerrnan RA: Group B streptococcal neonatal and infant infections, J PEDIATR82:707, 1973. 2. Barton LL, Feigin RD, and Lins R: Group B beta hemolytic streptococcal meningitis in infants, J PEDIATR 82:719, 1973. 3. Hood M, Janney A, and Damerton G: /3--hemolytic streptococcus Group B associated with problems of the perinatal period, Am J Obstet Gynecol 82:809, 1961.
Volume 86 Number 4
4. Hey DJ, Hall RT, Burry VF, and Thurn AN: Neonatal infections caused by Group B streptococci, Am J Obstet Gynecol 116:43, 1974. 5. Keitel HG, Hananian J, Ting R, Prince LN, and Randall E: Meningitis in the newborn infant, J PEDIATR61:39, 1962. 6. Weintraub MI, and Otto RN: Pneumococcal meningitis and endophthalmitis in a newborn, JAMA 219:1763, 1972.
Pneumococcal septicemia and meningitis
595
7. Tempest B: Pneumococcal meningitis in mother and neonate, Pediatrics 53:759, 1974. 8. Hogg P, and Bradley CD: Pneumococcus meningitis in the newborn, J PEDIATR26:406, 1945. 9. Fosson AR, and Fine RN; Neonatal meningitis, Clin Pediatr 7:404, 1968.
The Journal of P E D I A T R I C S
593
Pneumococcal septicemia and meningitis in the neonate Philip
G. Rhodes, M.D.,* Virgil F. Burry, M.D., Robert T. Hall, M.D., and
Robert C o x , M . D . , Kansas City, Mo.
with Streptococcuspneumoniae a r e u n c o m in the neonate. While group B streptococcal infections are appearing with increasing frequency,~-4 few reports of pneumococcal disease in the newborn infant have been published. Our experience indicates a need for increased awareness of this infection. In this report we describe five cases of neonatal septicemia and/or meningitis attributed to Streptococcus pneumoniae.
I N F E CT I O N S mon
PATIENTS
AND METHODS
The charts of all infants less than 28 days of age (during the period 1969-1973) who had positive cultures of e i t h e r b l o o d or c e r e b r o s p i n a l fluid for Streptococcus pneumoniae were reviewed. Four patients were identified. A n additional infant was reported to us by a physician in a nearby community. F o u r of the five infections occurred within the last two years. All organisms were identified by utilizing standard m e d i a on the basis o f colonial m o r p h o l o g y , a l p h a hemolysis, G r a m stain, and sensitivity to the optichin disc. Sheep blood and chocolate agars were used for initial isolation o f the o r g a n i s m s . Blood c u l t u r e s were placed in brain-heart infusion and thioglycollate media. Serotyping was not performed. N o n e of the organisms had the characteristics of the group B streptococcus. RESULTS Table I summarizes the clinical course, laboratory data, and outcome. Three infants presented with symptoms at less than 4 days of age. Clinically, the disease was severe and manifest by respiratory distress, cyanosis, temperature instability, and shock. Each of the *Reprint address: Children "sMercy Hospital, 24th and Gillham, Kansas C2ty, Mo. 64108.
three patients died within 36 hours after admission. A rapidly progressive p n e u m o n i a was seen radiographically and was also present at autopsy. A leukopenia was p r e s e n t in each i n f a n t and the p o l y m o r p h o n u c l e a r leukocyte response was deficient. Cultures of the vaginal cervix were obtained from two mothers and both were positive for Streptococcus pneumoniae. In addition to three newborn infants with early onset of illness, two other neonates presented with less apparent symptoms at 14 and 20 days of age, respectively. The disease was manifest by fever, lethargy, and irritability. One of the two patients presented with a temperature of 101~ The cerebrospinal fluid contained numerous cells and g r a m - p o s i t i v e , l a n c e t - s h a p e d o r g a n i s m s b u t t h e cultures were negative. The blood culture, however, was positive for Streptococcus pneumoniae under anaerobic conditions. Each of the patients with disease of late o n s e t r e c o v e r e d following t r e a t m e n t . N e i t h e r i n f a n t had the leukopenia seen in the early onset type of illness. DISCUSSION Meningitis or septicemia in 14 neonates has been diagnosed at our institution in the past two years. Three of these were due to Streptococcus pneumoniae and four were d u e to group B b e t a h e m o l y t i c s t r e p t o c o c c u s . A n o t h e r infant was reported to us from a nearby community during the past year. A fifth case occurred five years ago in our hospital. All other infections were caused by gram-negative organisms. In reviewing our cases, we were impressed by what appeared to be an increase in the incidence of Streptococcus pneumoniae infection. T h e r e also was a s t r i k i n g similarity in the pneumococcal infection and group B streptococcal illness currently being recognized in the neonate.
Vol. 86, No. 4, pp. 593-595
594
Rhodes et al.
The Journal of Pediatrics April 1975
Table I. Neonatal pneumococcal sepsis
Patient 3 days, female, white, 40 wks' gestation
1 day, male, white, 37 wks' gestation
Presenting symptoms
Peripheral white blood count (mm 3)
Respiratory distress, abdominal distention, tachycardia, temp (101.4~ Respiratory distress, temperature (97.4~
1,800; no pmn's seen; decreased platelets
2,200; 9% pmn's
1 day, female, white, 32 wks' gestation
Respiratory distress, temperature not recorded
2,200; 2% pmn's
20 days, male, black, 40 wks' gestation
Irritability, abdominal distention, watery stool, temperature (102.4~ Irritability, anorexia, temperature (102~
10,300; 37% pmn's
Cemb~mal fluM* 4 wbc's 0 pmn's, 4 lymphocytes, glucose 19, protein 35, positive culture, blood glucose 40 28 wbc's,12 pmn's, 16 lymphocytes glucose 82, protein 270, negative culture, blood glucose not done 1 wbc, 1 lymphocyte, glucose 44, protein 166, negative culture, k'-'~d glucose not
Positive pneumocoecal cultures
OuWome
Blood, nose, CSF
Pneumonia, died at 36 hours
Blood, nose, maternal cervix
Pneumonia, died at 15 hours
CSF,lungs (postmortem), maternal cervix
Pneumonia, died at 12 hours
Blood, throat
Recovered
Blood (anaerobic)
Recovered
e
14 days, male, white, 40 wks' gestation
16,600; 52% pmn's
7 wbc's, 2 pmn's, 5 lymphocytes glucose 75, protein 45, negative culture, blood glucose 94 645 wbc's 45 pmn's, 600 lymphocytes, glucose 32, protein 29, positive smear, negative culture, blood glucose 58
*Italic n u m b e r g i v e n in mg/dl. A b b r e v i a t i o n s u s e d : p m n = p o l y m o p h o n u c l e a r , w b c = white blood ceils.
There are isolated case reports of neonatal pneumococcal infection. Several have been associated with endocervical disease in the mother. 5,6 A recent case report described meningitis in the mother and in her infant.7A case report and review by Hogg and Bradley 8 reports 27 cases. A comprehensive review of neonatal meningitis by Fosson and Fine 9 lists 27 Streptococcus pneumoniae infectiOns as part of 457 cases of neonatal meningitis summarized from the literature. Neither of these reports alluded to the similarity to group B infection. We have no ready explanation for what appears to be an increase in the incidence of pneumococcal disease in the neonate at our hospital. We likewise have no explanation for the similar clinical course in the early onset of pneumococcal and group B beta hemolytic streptococcal infections. At the present time, both clinical entities carry the same poor prognosis.
Epidemiologically, it is i m p o r t a n t to d i f f e r e n t i a t e Streptococcus p n e u m o n i a e from alpha a n d beta streptococci. The morphologic colony appearance, hemolysis, and optichin disc can be helpful in the differentiation. One cannot rely on Gram stain with any degree of confidence. Although we did not do so, further differentiation by serologic means is important for closer epidemiologic surveillance. REFERENCES
1. Franciosi RA, Knostman JD, and Zimmerrnan RA: Group B streptococcal neonatal and infant infections, J PEDIATR82:707, 1973. 2. Barton LL, Feigin RD, and Lins R: Group B beta hemolytic streptococcal meningitis in infants, J PEDIATR 82:719, 1973. 3. Hood M, Janney A, and Damerton G: /3--hemolytic streptococcus Group B associated with problems of the perinatal period, Am J Obstet Gynecol 82:809, 1961.
Volume 86 Number 4
4. Hey DJ, Hall RT, Burry VF, and Thurn AN: Neonatal infections caused by Group B streptococci, Am J Obstet Gynecol 116:43, 1974. 5. Keitel HG, Hananian J, Ting R, Prince LN, and Randall E: Meningitis in the newborn infant, J PEDIATR61:39, 1962. 6. Weintraub MI, and Otto RN: Pneumococcal meningitis and endophthalmitis in a newborn, JAMA 219:1763, 1972.
Pneumococcal septicemia and meningitis
595
7. Tempest B: Pneumococcal meningitis in mother and neonate, Pediatrics 53:759, 1974. 8. Hogg P, and Bradley CD: Pneumococcus meningitis in the newborn, J PEDIATR26:406, 1945. 9. Fosson AR, and Fine RN; Neonatal meningitis, Clin Pediatr 7:404, 1968.