Septic arthritis caused by Streptococcus pneumoniae

BACKGROUND: Streptococcus pneumoniae is an uncommon agent of infective arthritis. In this report three cases of pneumococcal arthritis are described. METHODS: Retrospective review of synovial fluids processed in our laboratory yielding bacteria. The study period was from January 1991 to December 1995. The clinical records of patients with the clinical and microbiological diagnosis of septic arthritis were reviewed. RESULTS: Twenty-eight out of a total of 43 clinical records had the clinical and microbiological diagnosis of septic arthritis and three (11%) were caused by Streptococcus pneumoniae. The infective source in two of these three cases was probably the respiratory tract, and the most common location was the knee. CONCLUSIONS: In our cases immunosuppression seemed to be the major risk factor involved in the development of pneumococcal arthritis.     

Primary peritonitis caused by Streptococcus pneumoniae

OBJECTIVES: To examine the dilemmas for children, family, and mental health professionals posed by the presence of a delusional parent in a family, including someone with induced psychotic disorder (IPD); to identify frequently unrecognized problems; and to propose practical suggestions for professionals. METHOD: The pertinent literature on the effects of delusional parents on children, families, and professionals is reviewed. By way of 3 case vignettes, the dilemmas are identified and discussed. RESULTS: Delusional disorders are underdiagnosed, resulting in poor anticipation of their implications. Unanticipated family factors, such as "pursuit of isolation" and the related heightened risk of violence, contribute to the failure of professional interventions, which has been described as "therapeutic systems paralysis." CONCLUSIONS: These cases are complex, often requiring multisystemic involvement to reduce the risks of flight. violence, psychosis, posttraumatic stress disorder, and other psychiatric sequelae to children and other family members. The critical features of the innovative collaboration ("therapeutic consensus") required between professionals for successful therapeutic interventions with these families are described.     

Overwhelming postsplenectomy infection with vaccine-type Streptococcus pneumoniae in a 12-year-old girl despite vaccination and antibiotic prophylaxis

This report describes a 12-year-old girl who developed vaccine-type pneumococcal septicemia (type 4, Danish nomenclature) 2 years after splenectomy for recurrent idiopathic thrombocytopenia despite vaccination with the 23-valent vaccine 4 weeks before surgery and antibiotic prophylaxis with penicillin V. The disease presented as high fever with shivering and vomiting followed by disseminated petechiae and a deteriorated general condition. Initial laboratory studies showed severe sepsis with leucocytopenia and thrombocytopenia, a markedly elevated CRP, and disseminated intravascular coagulation. Despite antibiotic treatment, which was initiated with clindamycin, cefotaxime and trimethoprim/sulfamethoxazole and was switched to cefotaxime and penicillin after the result of the blood culture had been obtained, the patient had to be ventilated, and hemofiltration became necessary because of acute renal insufficiency. Furthermore, she required amputation of all her toes because of severe necrosis. No type-specific pneumococcal antibody titers were detected during and after infection. It remains unclear whether the susceptibility to Streptococcus pneumoniae was due to primary failure of antibody production or a decline in antibody levels after vaccination. Patients and/or their relatives should be informed that neither vaccination nor continuous antibiotic prophylaxis can guarantee full protection against infection with S. pneumoniae in patients after splenectomy.     

Molecular characterization of a globally distributed lineage of serotype 12F Streptococcus pneumoniae causing invasive disease

These studies have identified a major genetic lineage of capsule serotype 12F Streptococcus pneumoniae, which has maintained two different types of the pneumococcal surface protein A (PspA) virulence factor and caused invasive disease in geographically disjoint locations. Twenty outbreak strains from a Texas jail and Maryland day care center and 16 reference strains from Texas, Maryland, Washington, Michigan, Oklahoma, Missouri, Alaska, and Australia were examined. Although the Texas and Maryland outbreak strains were indistinguishable by IS1167 and boxA genotyping procedures, all strains examined were members of a genetically similar lineage. The microevolutionary history of pspA differed from that of the overall genetic background of the strains. Taken together, these findings suggested that the Texas and Maryland outbreaks were caused by different clones of a major genetic lineage of serotype 12F pneumococci, within which at least one PspA has been acquired via localized genetic recombination.     

Early recognition of Streptococcus pneumoniae in patients with community-acquired pneumonia

In order to elucidate the cause of osteonecrosis of the femoral head in spontaneously hypertensive rats (SHRs), which resembles the osteonecrosis of Perthes' disease, we observed the three-dimensional structure of vascular casts of the blood vessels feeding the femoral head using both optical and scanning electron microscopes. During the period of 9-15 weeks after birth, when osteonecrosis of the femoral heads in SHRs occurred frequently, the lateral epiphyseal vessels (LEVs), which were the main feeding vessels, entered from the lateral of the femoral heads. Anastomosing branches of LEVs between the epiphysis and the femoral neck were scarce even in the femoral heads showing normal ossification. It seemed that the development of LEVs in SHRs did not proceed normally in this period. Furthermore, remarkable segmental stenosis and the obstruction of LEVs were often recognized near the lateral of the femoral heads. These results suggest that LEVs in growing SHRs have the vascular structure that could cause an interruption of the blood supply to the femoral heads.     

A competence regulon in Streptococcus pneumoniae revealed by genomic analysis

Transformation in bacteria is the uptake and incorporation of exogenous DNA into a cell's genome. Several species transform naturally during a regulated state defined as competence. Genetic elements in Streptococcus pneumoniae induced during transformation were identified by combining a genetic screen with genomic analysis. Six loci were discovered that composed a competence-induced regulon. These loci shared a consensus promoter sequence and encoded proteins, some of which were similar to proteins involved in DNA processing during transformation in other bacteria. Each locus was induced during competence and essential for genetic transformation.     

Vancomycin in meningitis caused by penicillin G resistant Streptococcus pneumoniae

We report two cases of penicillin G-resistant pneumococcal meningitis in adults, with clinical and bacteriological failure of amoxicillin and negative or incomplete response to third generation cephalosporins. Meningitis occurred in a man treated for myeloma and in an elderly woman under prolonged intermittent amoxicillin therapy for chronic otitis. Such situations are known as exposing to pneumococcal meningitis and to resistance of the strain involved to penicillin G. Both patients were cured by vancomycin in continuous infusion associated with rifampicin or fosfomycin. Contrary to third generation cephalosporins, which have higher minimal inhibitory concentrations, vancomycin and rifampicin are still fully active against penicillin G-resistant pneumococcal strains. Thus, vancomycin administered in continuous infusion and associated with rifampicin and fosfomycin deserves to be tried as first-line treatment of pneumococcal meningitis in patients at risk of resistance to penicillin G.     

Acute bilateral amaurosis in sphenoid empyema caused by Streptococcus pneumoniae

PATIENT: A 14-year-old boy suffered from an acute bilateral blindness which occurred in 24-h time, accompanied by headache and raised temperature, with inconspicuous optic nerve head and fundus. After diagnosis of empyema with magnet resonance tomography (MRT) the sphenoid sinus was fenestrated and streptococcus pneumoniae isolated. Liquor and serology being inconspicuous, there was no evidence of leucaemic or autoimmune disease, intoxication or intracranial tumor. CLINICAL COURSE: The condition of the patient improved under systemic antibiotic therapy. The bilateral amaurosis remained and opticus atrophy developed. CONCLUSION: A bilateral amaurosis with descending opticus atrophy as a consequence of a sphenoiditis and spreading inflammation to the meninges and the optic nerve in the area of the chiasm is a rare event. The imaging technique of the MRT offers new opportunities for an early and more pointed diagnosis and therapy.     

Comparative activity of trovafloxacin and Bay 12-8039 against 452 clinical isolates of Streptococcus pneumoniae

BACKGROUND: We compared uptake of hospital and community-based support in elderly people disabled by chronic obstructive pulmonary disease (COPD), normal controls (NCs) and patients with Parkinsons disease, stroke, amputation, or arthritis (disabled controls; DCs). METHODS: There were 65 subjects (35 men) aged 70-93 years (mean 78) with COPD, 55 NCs [23 men; age range 71-90 years (mean 78)] and 53 DCs [27 men; age range 70-92 years (mean 78)]. Patients with COPD and DCs were outpatients with Nottingham extended activities of daily living (NEADL) score < 16. NCs came from a community survey. Subjects with COPD were clinically stable. All were cognitively intact. RESULTS: Mean NEADL scores (and range) were: 10.2 (3-15) for patients with COPD, 9.4 (3-15) for DCs (t=1.14, P=0.26) and 19.0 (11-21) for NCs. There was no difference in meals-on-wheels, district nurse or hospital or physiotherapy provision between patients with COPD and NCs, but those with COPD received more home care (P < 0.01). DCs received more home care (P=0.04), more district nurse input (P < 0.001) and more physiotherapy (P < 0.0001) than those with COPD. CONCLUSIONS: Despite moderate or severe disability, elderly patients with COPD receive little statutory domiciliary support. Reasons for this need further exploration.     

Fluoroquinolones as treatment for patients with lower respiratory tract infections caused by Streptococcus pneumoniae

BACKGROUND: Mycophenolate mofetil (MMF) has been previously shown to prevent functional deterioration in an experimental model of chronic renal allograft rejection. METHODS: In this retrospective case-control study, patients with chronic rejection who were receiving cyclosporine or tacrolimus and who had MMF added to their immunosuppressive regimen were compared with patients with chronic rejection who were not receiving MMF. Patients were matched for serum creatinine levels and transplant duration at the time MMF was begun. RESULTS: In the MMF group, the average dose of MMF was 1482 mg/day with an average duration of 19.3 months. Over 36 months, including 12 months before MMF and up to 24 months on MMF, there was no difference in serum creatinine levels between the two groups. Cyclosporine levels and dose were no different. CONCLUSIONS: In this small, retrospective, preliminary study, adding MMF to maintenance immunosuppression provided no clear benefit to renal allograft recipients with established chronic rejection. Larger prospective randomized studies are needed.     

Resistance to antibiotics of Streptococcus pneumoniae strains

Streptococcus pneumoniae strains are exhibiting increasing rates of antibiotics resistance. A rapid increase of resistance was seen not only to penicillin but also other antimicrobial agents and therefore this paper describes the study of resistance and multiresistance of pneumococci to 7 antibiotics: penicillin (P), erythromycin (E), clindamycin (CC), tetracycline (T), co-trimoxazole (SXT), cefotaxime (CTX) and vancomycin (Va), using the disk-diffusion technique according to NCCLS procedure. We tested a total of 218 S. pneumoniae strains isolated from various materials: from sputum (54), noses (117), throats (28) and different swabs specimens (19). The overall percentage of resistant isolates to penicillin was 3.7%, to erythromycin--4.1%, to clindamycin--10.6%, to tetracycline--17.4%, to co-trimoxazole--15.6%, to cefotaxime--2.3%. In the sputum was most the monoresistant strains (66.7%). The multiresistance was highest in the penicillin resistant pneumococci. With the exception of vancomycin, the number of resistant strains to non-beta-lactam antibiotics (erythromycin, clindamycin, tetracycline, co-trimoxazole) was higher in penicillin-resistant strains compared with penicillin susceptible isolates. All isolates were susceptible to vancomycin.     

Primary targets of fluoroquinolones in Streptococcus pneumoniae

Mutants of wild-type Streptococcus pneumoniae IID553 with mutations in parC were obtained by selection with trovafloxacin, levofloxacin, norfloxacin, and ciprofloxacin. All of the parC mutants were cross-resistant to the selecting agents but were not resistant to gatifloxacin and sparfloxacin. On the other hand, gyrA mutants were isolated by selection with gatifloxacin and sparfloxacin. The gyrA mutants were cross-resistant to gatifloxacin and sparfloxacin but were not resistant to the other fluoroquinolones tested. These results suggest that in wild-type S. pneumoniae the primary target of trovafloxacin, levofloxacin, norfloxacin, and ciprofloxacin is topoisomerase IV, whereas the primary target of gatifloxacin and sparfloxacin is DNA gyrase.     

Neonatal hand abscess, osteomyelitis and meningitis caused by Streptococcus pneumoniae

Pathologic splenic rupture is a rare and life-threatening complication of acute leukemia. It is even more uncommon as the initial manifestation, and only a few cases has been reported in the literature. Early recognition of this complication is vital because the prognosis is fatal without immediate treatment by splenectomy. We report the case of a spontaneous spleen rupture irreversibly complicating the onset of acute lymphoblastic leukemia in a 19-year-old man, in spite of splenectomy. In our case abdominal ultrasound was a good, non-invasive diagnostic test. Therefore, we believe that the course of the underlying disease and the physical condition of the patient dramatically influenced the disease evolution.     

Clinical outcome of invasive infections by penicillin-resistant Streptococcus pneumoniae in Korean children

One hundred six cases of invasive pneumococcal infections diagnosed from 1985 to 1996 were analyzed retrospectively. The types of infection were bacteremia without focus (45%), meningitis (19%), peritonitis (17%), pneumonia (bacteremic) (16%), and others (3%). Penicillin-nonsusceptible Streptococcus pneumoniae was first detected in 1989, and its incidence increased rapidly thereafter, reaching 89% in 1995. Initial empirical regimens were of parenteral beta-lactam antimicrobials with or without an aminoglycoside, but these were modified subsequently. Among the 72 nonmeningeal infections analyzed, a favorable response at 72 hours and death were observed in 83% and 2.5%, respectively, of 40 penicillin-susceptible infections, as compared with 86% (P = 1.0) and 7.1% (P = .45) of 14 infections due to intermediate strains and 61% (P = .07) and 11% (P = .22) of 18 due to resistant strains. The favorable-response rate and mortality among 49 patients not in initially critical condition were 92% and zero, respectively, as compared with 52% (P = .00027) and 17% (P = .008) of 23 in critical condition. The data suggest that clinical outcome of penicillin-nonsusceptible pneumococcal infection outside the CNS may be more closely related to clinical condition at presentation than to the level of resistance of the causative strain when such infection is treated with parenteral beta-lactams.