RECURRENT INFECTIONS
History
Michelle is a 7-year-old girl who presents to the A&E department with a 2-day history of fever, progressively worsening headache, vomiting and neck stiffness. She was born in Zimbabwe and moved to the UK at 2 years of age to live with her aunt, after her mother died from tuberculosis. She was admitted to hospital last year with pneumonia and developed an empyema, which required drainage. Streptococcus pneumoniae was isolated from blood cultures at that time. Since then she has had several episodes of otitis media treated by her GP, and has been off school quite frequently. Her aunt is not very sure about which immunizations she has received. There has not been any recent travel.
Examination
Michelle has a temperature of 38.8C, heart rate 120 beats/min, her blood pressure is 100/65 mmHg, respiratory rate 20/min and her oxygen saturation is 96 per cent in air. Her weight is 17 kg (second centile) and her height is 114 cm (ninth centile). She has multiple enlarged cervical lymph nodes, oral candidiasis, extensive dental caries and suppurative left otitis media. There is no rash, and cardiovascular, respiratory and abdominal examinations are normal. She is alert but uncomfortable, has marked neck rigidity and prefers the lights to be dimmed. There are no other abnormalities found on neurological examination.
INVESTIGATIONS
Normal
Blood
Haemoglobin 11.3 g/dL 11.1–14.7 g/dL
White cell count 23.8 109/L 4.5–14.5 109/L
Platelets 400 109/L 170–450 109/L
C-reactive protein 207 mg/L 6 mg/L
Glucose 5.5 mmol/L 3.3–5.5 mmol/L
Cerebrospinal fluid
White cells 1020 106/L 5 106/L
Red cells 0 0–2 106/L
Protein 2200 mg/L 200–400 mg/L
Glucose 0.9 mmol/L 2.8–4.4 mmol/L
Gram stain Gram-positive cocci Negative.
Questions
• What is the diagnosis for the acute illness and what is the management?
• What other problems should be considered?
• What other investigations might be appropriate?
Medicine
This child has acute bacterial meningitis, which is most likely to be due to S. pneumoniae. This diagnosis is strongly suspected from the acute history and the blood results, and confirmed by the CSF findings (see Case 62, p. 187). It may have developed secondary to the otitis media. She should be commenced on an appropriate antibiotic (most commonly intravenous ceftriaxone) and on intravenous dexamethasone. Michelle has a history of recurrent infections with two of these being severe. Any child with unusual, severe, recurrent or persistent infections must be evaluated for the possibility of an underlying immunodeficiency. In this case, recurrent S. pneumoniae infections raise concerns about hyposplenism, antibody deficiency and HIV infection. The findings of severe dental caries, oral candidiasis and cervical lymphadenopathy, together with the history of immigration from Zimbabwe and her mother dying from TB, strongly suggest HIV. Testing for HIV is done with informed consent of the person with parental responsibility for the child. If the test is positive, the child will gradually be given information and prepared for disclosure of the diagnosis when they are able to comprehend the implications of having HIV.
Examples of factors predisposing to recurrent infections
Primary Secondary
Antibody deficiency HIV
Complement deficiency Immunosuppressive drugs
Neutropenia Malnutrition
Chronic granulomatous disease Hyposplenism
Cellular immunodeficiency Cystic fibrosis
Ataxia telangiectasia Anatomical anomalies, e.g. skull base defect
KEY POINTS
• Consider immunodeficiency in all children with unusual, severe, persistent and recurrent infections.
• HIV testing should be part of the assessment of a child with recurrent infections.
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