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Key Features

Essentials of Diagnosis


  • High fever (> 39.4°C)

  • Leukocytosis (> 15,000/μL)


  • Fever, leukocytosis, and tachypnea

  • Localized chest pain

  • Localized or diffuse rales

  • Chest radiograph may show lobar infiltrate (with effusion)


  • Fever, leukocytosis

  • Bulging fontanelle, neck stiffness

  • Irritability and lethargy

All types

  • Diagnosis confirmed by cultures of blood, CSF, pleural fluid, or other body fluid.

General Considerations

  • Sepsis, sinusitis, otitis media, pneumonitis, meningitis, osteomyelitis, cellulitis, arthritis, vaginitis, and peritonitis are part of the spectrum of pneumococcal infection

  • Incidence rate of pneumococcal meningitis has decreased since incorporation of the pneumococcal conjugate vaccine into the infant vaccine schedule

  • However, pneumococcal meningitis is still more common than Haemophilus influenzae type b meningitis

  • Children with sickle cell disease, other hemoglobinopathies, congenital or acquired asplenia, and some immunoglobulin and complement deficiencies are unusually susceptible to pneumococcal sepsis and meningitis

  • Children with cochlear implants are at higher risk for pneumococcal meningitis

Clinical Findings

Symptoms and Signs

  • Clinical findings that correlate with occult bacteremia in ambulatory patients include age (6–24 months), degree of temperature elevation (> 39.4°C), and leukocytosis (> 15,000/μL)

  • In pneumococcal sepsis

    • Fever usually appears abruptly, often accompanied by chills

    • Respiratory symptoms may be absent

  • In infants and young children with pneumonia

    • Fever, and tachypnea without auscultatory changes are the usual presenting signs

    • Respiratory distress is manifested by nasal flaring, chest retractions, and tachypnea

    • Abdominal pain is common

  • In older children, the adult form of pneumococcal pneumonia with signs of lobar consolidation may occur, but sputum is rarely bloody

  • Meningitis

    • Characterized by fever, irritability, convulsions, and neck stiffness

    • Most important sign in very young infants is a tense, bulging anterior fontanelle

    • In older children, fever, chills, headache, and vomiting are common

    • Classic signs are nuchal rigidity associated with positive Brudzinski and Kernig signs

    • Opisthotonos, stupor, and coma may develop with progression of untreated disease

Differential Diagnosis

  • viral infection, urinary tract infection, unrecognized focal infection elsewhere in the body, salmonellosis, or early acute shigellosis.


Laboratory Findings

  • Leukocytosis is often pronounced (20,000–45,000/μL), with 80–90% polymorphonuclear neutrophils

  • Neutropenia may be seen early in very serious infections

  • Large numbers of organisms are seen on Gram-stained smears of endotracheal aspirates from patients with pneumonia

  • Isolation of S pneumoniae from a normally sterile site (eg, blood, CSF, joint fluid, middle ear fluid) or from a suppurative focus confirms the diagnosis

Diagnostic Procedure

  • Pneumococcal meningitis is diagnosed by lumbar puncture

  • CSF usually shows an elevated white blood cell (WBC) count of several thousand, chiefly polymorphonuclear neutrophils, with decreased glucose and elevated protein levels



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