[CIS-PAGID] Pneumococcal sepsis

[Patel, Niraj C]

Dear All,
I am recently out of fellowship and need more experienced folks for input.

A colleague shared with me a previously healthy 4 yo Vietnamese girl who presented with Streptococcus pneumoniae bacteremia, sepsis, and empyema.  She had received Prevnar (does not contain serotype 3) x 3 doses, and then PCV13 (does contain serotype 3) x 1 dose as part of her routine childhood immunizations.   At presentation she had pancytopenia which resolved over her course of illness.  An ultrasound showed the presence of a spleen.  An HIV test was negative.  The initial labs soon after admission are as follows:
IgG 480 (468-1,328)
IgA 80 (33-187)
IgM 31 (31-184)
CH50 16 (22-60)
Tetanus 0.52
Haemophilus B 0.85
Diptheria 0.14

She was subsequently immunized with Pneumovax about 3 weeks into her illness, and post pneumococcal titers were assessed 4 weeks after immunization (or 7 weeks after symptoms began) and shown below.

Pneumococcal Antibodies:
Serotype          PrePneumovax             Post Pneumovax
                        (Acute Illness)
1                                             5.01                        20.87
3                0.31                              0.95
4                0.40                              11.11
8                0.25                              17.02
9                0.26                              5.66
12               <0.38                            4.90
14               1.07                              >6.02
19               0.76                              16.65
23               0.40                              >2.79
26               1.40                              31.14
51               1.02                              23.33
56               0.42                              7.96
57               1.07                              27.90
68               0.59                              12.25

The causative Streptococcus pneumoniae bacteria was identified as serotype 3.  She had excellent responses to all serotypes after immunization except to serotype 3.  Poor response after one dose of PCV 13 (containing serotype 3) has been reported.  But after immunization with pneumovax following natural infection with serotype 3, the titer for serotype 3 did not make much sense to me.  She completed 3 weeks of ceftriaxone and is doing well.  Should I be concerned about an immunodeficiency?      Would you pursue any additional evaluation?
Thank you in advance for your assistance.

Niraj


Niraj Patel, MD MS

Department of Pediatrics
Infectious Diseases and Immunology

Levine Children's Hospital
Carolinas Medical Center
Charlotte, NC 28232-2861



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