Case Study Of Streptococcus Pneumoniae Transmission

A Case Study: Pneumonia

Muhammad Zeeshan Zafar*

Faculty of Pharmacy, University of Sargodha, Pakistan

*Corresponding Author:
Zafar MZ
Faculty of Pharmacy
University Of Sargodha
Pakistan
Tel: 03466189496
E-mail:[email protected]

Received date: July 8, 2016; Accepted date: July 29, 2016; Published date: August 4, 2016

Citation: Zafar MZ (2016) A Case Study: Pneumonia. Occup Med Health Aff 4:242. doi: 10.4172/2329-6879.1000242

Copyright: © 2016 Zafar MZ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Pneumonia (from the Greek pneuma, “breath”) is a potentially fatal infection and inflammation of the lower respiratory tract (i.e., bronchioles and alveoli) usually caused by inhaled bacteria and viruses has both properties (Streptococcus pneumoniae, aka pneumococcus). The illness is frequently characterized by high fever, shortness of breath, rapid breathing, sharp chest pain, and a productive cough with thick phlegm. Pneumonia that develops outside the hospital setting is commonly referred to as community-acquired pneumonia. Pneumonia that develops 48 hours or later after admission to the hospital is known as nosocomial or hospital acquired pneumonia. In this case report we review the presentation and management of pneumonia involving the respiratory system. The aim of this report is to alert the clinicians to the potential diagnosis of pneumonia treatment. This is the case report of 3 months old boy with Pneumonia. He was diagnosed with pneumonia. His treatment was starting and after 7 days, he became completely recovered. For his disease diagnosis different tests are also performed.

Keywords

Community-acquired pneumonia (CAP); Pneumonia; Diagnosis; Drug uses; Doctors treatment; Respiratory disorders

Introduction

Community-acquired pneumonia (CAP) is a common and potentially serious illness that is associated with morbidity and mortality. Only half of the cases had an etiology microorganism identified.

Dozens of types of bacteria can cause pneumonia. Bacterial pneumonia is caused by an infection of the lungs and may present as a primary disease or as secondary disease in a debilitated individual or following a viral upper respiratory infection, such as influenza or the common cold.

Community-acquired pneumonia tends to be caused by different microorganisms than those infections acquired in the hospital.

Pneumonia caused by Streptococcus pneumonia remains the most common cause of all bacterial pneumonias. High-risk groups include older adults and people with a chronic illness or compromised immune system. This type of pneumonia is a common complication of chronic cardiopulmonary disease (e.g., heart failure) or an upper respiratory tract infection [1].

The knowledge of etiology of pneumonia in low and middle income countries is based on two types of studies: prospective, microbiologybased studies and vaccine trial studies, where indirect evidence of vaccine efficacy for the prevention of pneumonia can be used to estimate the disease burden of each pathogen.

Prospective studies have identified Streptococcus pneumonia as the leading cause of bacterial pneumonia among children in developing countries, responsible for 30-50% of pneumonia cases.

The second most common is Haemophilus influenza type b followed by Staphylococcus aureus and i Other bacteria are Mycoplasma pneumonia and i , causing atypical pneumonia non-typable H. influenza (NTHI) and non-typhoid Salmonella spp. Furthermore, studies of lung aspirate have identified Mycobacterium tuberculosis as an important cause of pneumonia.

Case Presentation

A 3 months old boy was brought to the DHQ hospital Gujranwala, Pakistan. He presenting complains are cough, fever, dyspnea, vomiting and diarrhea from the period of last 5 days.

He ate contaminated food and drinks few days ago so, that is the main cause of this. Before to come here they also went in Ahsan hospital Daska, Pakistan, but he did not understand a disease, he gave him Amoxicilline 125 mg/5 ml and Dimenhydrinate 12.5 mg/4 ml syrups.

After 3 days of treatment, they came into DHQ hospital Gujranwala. Other chief complaints by the patient include problem in breathing may be due to cold feeling.

His physical examination showed temperature 102°F. Respiratory rate is 28 beats/min, hear crept on auscultation, he weighed 5 kg. His caused of fever may be some cold exposure.

He was treated with Cefixime 100 mg/5 ml, Ibuprofen 100 mg/5 ml, pseudoephedrine 15 mg/5 ml and Dimenhydrinate 12.5 mg/5 ml in DHQ hospital. Doctor advised him for laboratory tests and admitted him in a Hospital.

Diagnosis

CBC (Complete blood count), CXR (Chest X-Ray), Electrolyte count tests are performed. CBC showed that his TLC Total leukocytes count) and lymphocytes concentrations had increased, neutrophils decreased.

His neutrophils concentration now 22% whose normal value is 45 to 75% and lymphocytes concentration increased whose normal value is 20 to 45% (Table 1).

TestValueUnitsExpected value
Hb%12.1g/dl14 to 24
WBC12100mm3new born5500 to 18000/cm
Platelet count616000mm3150000 to 400000
Different Leucocyte count (DLC)
Neutrophils22%45 to 75%
Lymphocytes70%20 to 45%
Eosinophils4%02 to 06%
Monocytes4%02 to 10%
RBC5.5710>12/litre3.5 to 5.5
MCV79.2F175 to 100
HCT36.2%35 to 55
MCH26.5Pg25 to 35
MCHC33.4g/dl31 to 38

Table 1: Complete blood count test.

On electrolyte counting test showed that calcium concentration decreased which is 7.8 now its normal value is 8.5 to 10.5 (Table 2).

TestValueUnitExpected value
Sodium136mEq/L135……….145
Potassium4.4mEq/L3.8………5.0
Calcium7.8mEq/L8.5……….10.5

Table 2: Electrolyte counting test.

On Chest X-Ray detected a white patch on left side upper lobe, which indicated that pneumonia is confirmed. So when the pneumonia is confirmed then Doctor started his actual treatment (Figure 1).

Treatment

His treatment include injection Cefotaxime 250 mg intravenous B.D, injection Ampicillin 125 mg intravenous after 6 hours, given Nebolization with ventoline, and Oxygen now SOS, and a Panadol drops, 10 drops. His vitals were checked.

The patient recovered slowly and after 2 days treatment Doctor again checked him and gave him another treatment claritex drops 1/2 drops and Calcium 2/2.

At the third day of his admission in hospital Doctor checked him, his physical examination showed now that temperature reached at 100°F, diarrhea and vomiting are also decreased. Doctor advised his mother to continue this medication, care and feed properly.

At the fifth day continuously five days treatment child become completely recovered and doctor discharged them at 5/10/2014.

Discussion

Community-acquired pneumonia (CAP) is a frequent cause of hospital admission and mortality in elderly patients worldwide. The clinical presentation, etiology, and outcome of community acquired pneumonia in elderly differs from that of other population [2,3].

This patient had community-acquired bacterial pneumonia on the basis of his physical examination and chest radiograph.

The most common cause of community-acquired bacterial pneumonia is Streptococcus pneumoniae . The finding of gram-positive diplococci in the blood is consistent with pneumococcal disease as well. Approximately 25 to 30% of patients with pneumococcal pneumonia will have positive blood cultures. Group A streptococcus is another possible organism because it can cause bacteremic pneumonia and can possibly appear as a gram-positive diplococcus. However, in a blood culture, group A streptococci are much more likely to be present as gram-positive cocci in chains. The two streptococci are easily distinguished by the fact that S. pneumoniae is alpha-hemolytic and bile soluble whereas group A streptococcus is beta-hemolytic and bile insoluble but bacitracin susceptible.

Determination of precise etiology of pneumonia is difficult due to the lack of sensitive and specific tests. Many clinicians treat pneumonia empirically with minimal laboratory or radiographic evaluation and thus up to 80% of non-bacterial pneumonia may be treated with antibiotics. This approach is satisfactory when clinical risk is deemed to be low [4].

Conclusion

Our main findings and conclusion were:

Community-acquired pneumonia in elderly patients is a common and serious problem encountered in clinical practice. Elderly patients with community-acquired pneumonia have different clinical presentation and higher mortality.

From this case study we conclude that main causes for pneumonia and what are these treatments.

As we read that here patient is not cured after its first treatment because disease was not identied our main purpose is to first diagnose a disease and then to start rational treatment.

Acknowledgment

I take this opportunity to express my profound gratitude and deep regards to Dr. Taha Nazir (Assistant Professor and Course Director Microbiology & Immunology, Faculty of Pharmacy, University of Sargodha)for his exemplary guidance, monitoring and constant encouragement throughout the course of this case report. Also thanks to the staff at the Pediatrics department at the DHQ hospital Gujranwala.

Recommendations

Increase caretakers' recognition of pneumonia signs through extensive health communication activities by strengthening the third component of IMCI (improving family and community practices).

Antibiotics improve outcomes in those with bacterial pneumonia. Antibiotic choice depends initially on the characteristics of the person affected, such as age, underlying health, and the location the infection was acquired.

Stay away from people who have colds, the flu, or other respiratory tract infections.

If you haven't had measles or chickenpox or if you didn't get vaccines against these diseases, avoid people who have them.

Preventive measures are under observations i.e., avoid contaminated food, drinks purified water etc.

References

  1. Schumann L (2006) Pneumonia. In: Copstead LEC, Banasik JL (eds.). Pathophysiology(3rd edn) St WHO.
  2. World Health Organization (2002) Promoting rational use of medicines: core components: WHO policy perspectives of medicines. No.5. Geneva: WHO.
  3. World Health Organization (2009) Medicines use in primary care in developing and transitional countries: Fact book summarizing results from studies reported between 1990 and 2006. Document No. WHO/EMP/MAR/2009.3. Geneva: WHO.
  4. Levinson W (2012) LANGE: Review Of Medical Microbiology and Immunology (12th edN) (Part IX brief summaries of medical important organisms).

Figure 1: Chest X-Ray: In this a white patch seen on left side upper lobe of lung which indicated pneumonia.

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Discussion

The girl was diagnosed with Streptococcus pneumoniae (pneumococcus) infection. S. pneumoniae is a gram-positive, encapsulated bacterium, and an important and commonly encountered bacterial pathogen in humans. It is often found as a normal commensal in the nasopharynx of healthy adults and children. It does however have the potential to become pathogenic. In developing countries, including South Africa, pneumococcus remains the most common and important disease-causing organism in infants. Although exact numbers are difficult to obtain, it is estimated that pneumococcal infection is responsible for more than one million of the 2.6 million annual deaths due to acute respiratory infection in children younger than 5 years. Case fatality rates associated with invasive disease vary widely but can approach 50% and are greatest in patients who develop meningitis. The bacterium does so by escaping local host defenses and phagocytic mechanisms, and penetrates the CSF either through choroid plexus/subarachnoid space seeding from bacteraemia or through direct extension from sinusitis, otitis media or mastoiditis. Presently, it is the most common bacterial cause of meningitis, accounting for 47% of cases.

Most individuals who are colonised with pneumococcus carry only a single serotype at any given time. The duration of colonisation varies depending on bacterial characteristics such as serotype and host characteristics. Invasive disease is usually related to recent acquisition of a new serotype. However, in most healthy hosts, colonisation is not associated with symptoms or disease but allows for the continued presence of pneumococcus within the population. The bacterial capsule consists of repeating oligosaccharides and based on antigenic differences within these capsular polysaccharides, greater than 91 serotypes of pneumococcus have been identified. From these a heptavalent pneumococcal conjugate vaccine (PCV7 vaccine) has been designed which contains the 7 most common pneumococcal serotypes causing 70% of the invasive infections in children. With the implementation of childhood vaccinations (since 2000 in USA, 2009 in RSA) using this heptavalent conjugate vaccine (prevnar) for pneumococcus, colonisation rates have decreased in children receiving the vaccine. As a result, adults and other children living in the same household become less exposed and the incident cases of pneumoccocus are significantly reduced because of the phenomenon of herd immunity.

In this discussion we will explore the current understanding of how pneumococcus is able to colonise the nasopharynx, the ways in which the bacterium evades the innate immune system and how it is able to cause disease. With the aid of our graphics we will discuss the processes involved in various bacterial dissemination routes, such as to the middle ear and meninges, dissemination to the lungs and then via the bloodstream to the meninges  or dissemination via a bacteraemia to the meninges. We will also go into a more detailed discussion of the  strategies employed by the bacterium to evade the innate immune system. Pneumococcal vaccinations will not be discussed in any detail here, but will be  detailed in a separate case study.

Colonisation of the upper respiratory tract

Pneumococcus is a commensal bacterium that is transmitted between humans via aerosols. In this way the bacteria colonise the nasopharynx, and typically do not cause any disease in healthy individuals. However, amongst children younger then 5 years, the elderly and immunocompromised individuals, especially those who are HIV-infected, asplenic, have complement deficiencies, humoral immunity defects or neutrophil dysfunction, they are all at a greater risk of disease resulting in infections at more distant sites such as pneumonia, otitis media, meningitis, encephalitis and systemic bacteraemia.

A common dissemination route, particularly in young children, is the ascent of the bacteria via the Eustachian tube to the middle ear causing otitis media. Prolonged infection in this compartment can permit spread of bacteria directly into the CSF through the mastoid sinuses resulting in meningitis. This is the route through which our case study patient was repeatedly infected. In the case of our index patient we know that she cleared infection on every admission. We know that although she is HIV-positive, her immune system is most probably robust due to the viral suppressive effect of HAART (her  viral load  is undetectable) with a CD4 count in a normal range. We also know from our laboratory investigations that she did not develop a bacteraemia because her blood cultures were always negative therefore her recurrent infections into the meninges was due to direct access to CSF from the middle ear or mastoid sinuses.

Another common route  of dissemination from the nasopharynx, particularly in adults, is seeding of the lower respiratory tract and invasion of the lungs resulting in pneumonia. Inflammation of the lungs can then permit escape of bacteria into the bloodstream. Entry of bacteria into the systemic blood system can result in bacteraemia, but can also lead to invasion of the CSF via the capillary networks that traverse the choroid plexus or subarachnoid space causing meningitis.  Alternatively bacteria can penetrate the nasopharyngeal submucosa by translocation across the epithelium and subsequent translocation of capillary endothelial cells entering the blood stream and causing bacteraemia.

Once in the bloodstream, bacteria can cross endothelial cell barriers and enter the CSF through the blood vessels traversing the choroid plexus or subarachnoid spaces and cause meningitis. Endothelial cells of the blood-brain barrier can also be penetrated allowing bacterial spread into the CNS, resulting in encephalitis; but this occurs less often.

Now that we understand bacterial dissemination on a gross level we can take a closer look at how the bacteria  cross the upper respiratory tract epithelium and translocate the capillary endothelium to gain access to the bloodstream.

Pneumococcus interferes with the secretory antibody pathway of the upper respiratory track.  Anti-capsular antibodies play an important role in control of pneumococcal infections. B lymphocytes in the submucosa secrete IgM and dimeric IgA which is transported across the mucosal epithelium of the upper respiratory tract by transcytosis. The polymeric immunoglobulin receptor (PigR), expressed on the basolateral membrane of epithelial cells, binds to the J chain of IgM and dimericIgA. The bound antibodies are then transported in a vesicle through the cell and released at the apical membrane. Here proteosomal cleavage of the receptor at the membrane surface releases the antibody keeping the secretory component attached.

The pneumococcus, which is found in the upper respiratory tract on the apical side, the mucosal epithelium expresses its own surface protein known as PspC. This protein facilitates translocation of bacteria by reverse transcytosis through the upper respiratory epithelial cells. This is achieved by PspC essentially hijacking the polymeric immunoglobulin receptor (PigR) which normally transports IgM and dimeric IgA to the mucosal surface. Although primarily expressed at the epithelial basolateral cell surface, PigR is found at a low level on the apical membrane. Binding of bacterial PspC to the secretory component of PigR induces reverse transcytosis and in this way delivers intact bacteria into the submucosa. PigR is not expressed in the lower respiratory tract and therefore does not play a role in lung disease.

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