Overwhelming Pneumococcal Sepsis in a Patient with Splenic Hypoplasia

Abstract

Department of Infectious Diseases, Yokohama Municipal Citizen’s HospitalA 58-year-old female was admitted due to severe sepsis and multi-organ failure with a fulminant purpuric rash.Meropenem, vancomycin and levofloxacin were administered, although no focus of infection was detected. However,computed tomography revealed a profoundly hypoplastic spleen, and a blood smear detected Howell-Jolly bodies.Blood cultures grew Streptococcus pneumoniae (serotype 22F) three hours after admission. The patient was finallydiagnosed as overwhelming pneumococcal sepsis with hyposplenism precipitated by splenic hypoplasia. Cliniciansshould pay attention to the splenic size and Howell-Jolly bodies in cases of sepsis of unknown origin.Keywords: Streptococcus pneumoniae, splenic hypoplasia, Howell-Jolly bodies, purpura fulminans, Pneumovaxµ 23,23-valent pneumococcal polysaccharide vaccineCASE REPORTA 58-year-old female was admitted to YokohamaMunicipal Citizen’s Hospital due to severe sepsis, andmulti-organ failure in April 2013. She developedgeneral fatigue, diarrhea and a high-grade fever of42°C on the day before hospitalization. On the day ofadmission, the patient also developed dyspnea. She hada past surgical history of osteosarcoma at the age of 23years and breast cancer at the age of 49 years requiringa mastectomy and axillary lymphadenectomy, followedby adjuvant chemotherapy and hormone therapy forfive years. She had not been previously vaccinated withthe 23-valent pneumococcal polysaccharide vaccine(PPSV23).In the emergency room, her vital signs were asfollows: blood pressure was 99/73mmHg, heart ratewas 100 beats/min, respiratory rate was 45 breaths/min, body temperature was 33.3°C and Glasgow ComaScale was E3V4M6 (total 13/15).Physical examination revealed purpura on her faceand extremities (Figure 1), whereas other systemexaminations were unrevealing. Despite a whole bodycomputed tomography (CT) scan, urine Gram staining,and rapid diagnostic testing (group A streptococcus,Streptococcus pneumoniae, and Influenza) from thepatient’s throat, it was not possible to detect theAuthor for correspondence: Kenichiro YaitaDepartment of Infectious Diseases, Yokohama Municipal Citizen’s Hospital, 56 Okazawa-cho, Hodogaya-ku,Yokohama, Kanagawa 240-8555, JapanE-mail: kyaita81@gmail.comReceived for publication 26 September 2013 and accepted in revised form 29 January 2014© 2014 The Japan Primary Care AssociationGeneral Medicine 2014, vol. 15, no. 1, p. 68–71.