J Am Board Fam Pract: first published as 10.3122/jabfm.17.1.68 on 10 March 2004. Downloaded from

BRIEF REPORTS Fatal Pneumococcal Sepsis from a Tuboovarian Abscess

Michael W. Felz, MD, and Christopher J. Apostol, DO

Although Streptococcus pneumoniae is frequently as- shaped diplococci within polymorphonuclear cells sociated with human respiratory illnesses, only and monocytes. Gram staining of buffy coat and rarely have pneumococcal organisms been impli- revealed identical Gram-positive cated in gynecologic infectious syndromes. We re- diplococci. Chest radiograph was normal. Serology port a recent case of fatal S pneumoniae was negative for HIV. The clinical impression was from a tuboovarian abscess discovered at autopsy septic shock with disseminated intravascular coag- and review the literature pertaining to this previ- ulation (DIC). Blood culture revealed growth of S ously unreported clinical occurrence. pneumoniae, sensitive to penicillin, at 12 hours after admission. Case Report Despite aggressive management with intubation, A 35-year-old female nurse noted 5 days of gray volume expansion, , bicarbonate, calcium vaginal discharge and worsening right hip pain, gluconate, and 3 pressor agents, relentless clinical followed the next day by malaise, chills, , leth- deterioration ensued followed by death in 6 hours. argy, and weakness. After collapse in an emergency At autopsy, a 6-cm tuboovarian abscess (TOA) was department, she was intubated and transferred to documented, with pathologic evidence of severe the Medical College of Georgia by helicopter. Her suppurative of the right ovary. Gram- past medical history was unremarkable. She was the positive lancet-shaped diplococci were demon- mother of 5 children. On initial evaluation, she was strated on special stains. The abscess wall was well- hypotensive (60/45 mm Hg), tachycardic (heart organized, consistent with presence of infection for rate of 128 beats/min), and hypothermic (33°C), several days. There was no evidence of pneumonia, meningitis, endocarditis, arthritis, or occult abscess with oozing venipuncture sites. Copious foul vagi- http://www.jabfm.org/ nal discharge was noted on pelvic examination. elsewhere. Widespread DIC was present. Laboratory testing revealed a white blood cell The final cause of death was overwhelming count of 1200/mm3 with 24 band forms and plate- pneumococcal sepsis with refractory metabolic let count of 34,000/mm3. Blood gas analysis acidosis, septic shock, and DIC in a patient with previous good health. The surprising finding at showed an arterial pH of 7.05 and pO2 of 71 mm Hg while the patient was receiving 100% oxygen. autopsy of pneumococcal TOA is, to our knowl- Serum bicarbonate was 11 mEq/L, lactic acid was edge, the first published report implicating S. pneu- on 2 October 2021 by guest. Protected copyright. 16.3 mmol/L, and creatinine was 5.5 mg/dL. Ion- moniae in primary pelvic inflammatory disease and ized hypocalcemia of 3.5 mg/dL was documented. fatal bacteremia. Prothrombin time was 26.8 seconds with interna- tional normalized ratio of 5.2, and activated partial Discussion thromboplastin time was Ͼ100 seconds (reference Neisseria and trachomatis are range, 22–35 seconds). Wright staining of a buffy- the most frequent organisms recovered from cervi- coat smear revealed numerous encapsulated lancet- cal cultures in patients with pelvic inflammatory disease. Specimens obtained by laparoscope, how- ever, are often polymicrobial and have yielded sin- Submitted, revised 28 April 2003. From the Department of Family Medicine, Medical Col- gle or mixed isolates of Bacteroides, Peptostreptococcus, lege of Georgia, Augusta. Address correspondence to Chris- Prevotella, Gardnerella, and Actinomyces species, N topher J. Apostol, DO, Department of Family Medicine, Medical College of Georgia, Augusta, GA 30912 (e-mail: gonorrhea, C trachomatis, , Strep- [email protected]). tococcus agalactiae, Escherichia coli, Haemophilus influ-

68 JABFP January–February 2004 Vol. 17 No. 1 J Am Board Fam Pract: first published as 10.3122/jabfm.17.1.68 on 10 March 2004. Downloaded from enzae, Streptococcus pyogenes, Neisseria meningitidis, purulent aspirate. Rapid recovery accompanied and, as in our case, S pneumoniae.1 Pathogenesis of penicillin therapy. The authors stress the unusual the last 4 organisms in this list has been attributed instance of postmenopausal TOA caused by pneu- to ascending vaginal infection and to the substantial mococci, in contrast to the common occurrence of histologic similarity between the epithelium of the TOA from C trachomatis or N gonorrhea in pre- respiratory and upper genital tracts. Aggressive S menopausal females as a result of pelvic inflamma- pneumoniae , such as in our case, may be tory disease. related to alteration in penicillin binding proteins, In a unique report from Delaware,8 3 girls aged limited macrophage surface receptors for capsular 8 to 12 were thought to have appendicitis based antigens, ineffective anticapsular antibody, or resis- on fever, abdominal pain, rebound tenderness, and tance to phagocytosis conferred by the polysaccha- leukocytosis. At laparotomy, however, these chil- ride capsule, the major determinant of this organ- dren were found to have TOA, and positive cul- ism’s virulence.2 tures of blood, abscess contents, and/or peritoneal Prior case reports of pneumococcal TOA have fluid for S pneumoniae. All recovered with penicillin involved less severe illness and more favorable out- therapy, although 2 had stormy postoperative comes than occurred in our patient. For example, a courses. None had pathologic findings of appendi- 23-year-old woman in Sweden with fever and ab- citis. The authors were unable to identify a primary dominal pain was found to have a large pelvic ab- focus of pneumococcal infection in these children scess.3 At laparotomy, 500 mL of purulence was and cite 2 other cases reported in young girls at drained, with culture of pneumococcus. Full re- age 4.9,10 covery followed intravenous penicillin therapy. No Finally, in a case from Spain reminiscent of our primary focus of infection or portal of entry was patient,11 a 35-year-old woman was evaluated for detected. A 19-year-old woman in North Carolina fever, left hip pain, abdominal rebound, and a left developed fever and abdominal rebound tender- pelvic mass. At laparotomy, a left TOA was excised. ness, diagnosed as postpartum endometritis, with Cultures revealed S pneumoniae. Full recovery ac- blood cultures positive for S pneumoniae.4 A chest companied penicillin treatment. The authors em- radiograph was normal. Full recovery followed par- phasize the rarity of pneumococcal TOA, especially enteral ampicillin therapy. Simultaneous infection in the absence of recurrent PID. In recent compre- occurred at age 12 hours in her newborn infant, hensive reviews, both Taylor and Sanders12 and who had fever, tachypnea, lethargy, and positive Capdevila et al13 reiterate the infrequent occur- cultures for S pneumoniae in blood and cerebrospi- rence of pneumococcal invasion of the fallopian http://www.jabfm.org/ nal fluid. The infant recovered fully with intrave- tubes, ovaries, and peritoneum. They advance sev- nous penicillin therapy. The authors postulate that eral hypotheses as to portals of entry and predis- maternal genital colonization was complicated by posing conditions leading to these unusual infec- systemic spread to mother and infant during nor- tions. mal vaginal delivery. We postulate that our patient’s initial site of 5

Westh et al reviewed 24 patients with pneumo- infection was pelvic, as manifested by vaginal dis- on 2 October 2021 by guest. Protected copyright. coccal genital infections reported worldwide since charge and right hip pain referred from a develop- 1963. Predisposing conditions included postpartum ing TOA. Ascending vaginal infection led to tubal states, use, gynecologic surgery, abscess formation and subsequent bacteremia ac- recent , and tampon usage. All patients companied by rapid hematogenous dissemination were successfully treated; no fatalities were re- and septic shock. Fulminant progression to death ported. A 46-year-old woman in Zaire6 underwent followed within hours, despite appropriate therapy laparotomy for abdominal pain and was found to for an organism proven sensitive to penicillin. We have bilateral 10 cm TOAs caused by S pneumoniae believe that the sudden, severe, culture-positive cultured from purulent drainage. The authors cite pneumococcal infection was the cause of death. the rarity of prior reports of pneumococcal TOA. Unlike most pneumococcal bacteremias, however, Rahav et al7 describe a 52-year-old woman in Israel this infection originated in the , not the pul- with abdominal pain, fever, and a pelvic mass 5 monary parenchyma. We recognize that earlier years after . At laparotomy, a 9-cm left recognition and management would have been TOA was detected. S pneumoniae was isolated from challenging because of the rapid, relentless pro-

Fatal Pneumococcal Tuboovarian Abscess 69 J Am Board Fam Pract: first published as 10.3122/jabfm.17.1.68 on 10 March 2004. Downloaded from gression of illness but may have held the only hope 5. Westh H, Skibsted L, Korner B. Streptococcus for a less tragic outcome for this unfortunate wife pneumoniae infections of the female genital tract and mother. and in the newborn child. Rev Infect Dis 1990; 12:416–22. 6. Hadfield TL, Neafie R, Lanoie LO. Tubo-ovarian Conclusion abscess caused by Streptococcus pneumoniae. Human Our case adds to the body of knowledge describing Pathol 1990;21:1288–9. the rare association of S pneumoniae with genital 7. Rahav G, Ben-David L, Persitz E. Postmenopausal infections such as TOA and constitutes the first pneumococcal tubo-ovarian abscess. Rev Infect Dis reported instance of fatal sepsis from a pneumococ- 1991;13:896–7. cal TOA. The disastrous consequences of bactere- 8. Sirotnak AP, Eppes SC, Klein JD. Tuboovarian ab- mic illness from such an occult source as the ovary scess and peritonitis caused by Streptococcus pneu- are likely to complicate physician detection and moniae serotype 1 in young girls. Clin Infect Dis early intervention. 1996;22:993–6. 9. Meis JF, Festen C, Hoogkamp-Korstanje JA. Pyo- salpinx caused by Streptococcus pneumoniae in a young We are grateful to Drs. Lawrence D. Devoe and Michael S. girl. Pediatr Infect Dis J 1993;12:539–40. Macfee, MCG Department of and Gynecology, for their clinical insights and manuscript review. 10. Casiro OG, Gochberg F, Drachman R. Pneumococ- cal pyosalpinx in a prepubertal child. Isr J Med Sci References 1980;16:865–6. 1. Soper DE. Pelvic inflammatory disease. In: Faro S, 11. Abalde M, Molina F, Guerrero A, Llinares P. Strep- Soper DE, editors. Infectious diseases in women. tococcus pneumoniae peritonitis secondary to a Philadelphia: Saunders, 2001; p. 267–78. tubo-ovarian abscess. Eur J Clin Microbiol Dis 1998;17:671–3. 2. Musher DM. Streptococcus pneumoniae. In: Man- dell GL, Bennett JE, Dolin R, editors. Principles and 12. Taylor SN, Sanders CV. Unusual manifestations of practice of infectious diseases, 5th ed. Philadelphia: invasive pneumococcal infection. Am J Med 1999; Churchill Livingstone; 2002. p. 2131–46. 107:12S–27S 3. Berntsson E, Cullberg G, Trollfors B. Intraabdomi- 13. Capdevila O, Pallares R, Grau I, Tubau F, Linares J, nal pneumococcal abscess. Scand J Infect Dis 1978; Ariza J, Gudiol F. Pneumococcal peritonitis in adult 10:249–50. patients: report of 64 cases with special reference to 4. Robinson EN Jr. Pneumococcal endometritis and emergence of resistance. Arch Intern Med neonatal sepsis. Rev Infect Dis 1990;12:799–801. 2001;161:1742–8. http://www.jabfm.org/ on 2 October 2021 by guest. Protected copyright.

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