Pneumonococcal Pneumonia Complicated with Empyema and Hemolytic Uremic Syndrome

Introduction: Hemolytic Uremic Syndrome (HUS) is a clinical syndrome characterised by the triad of thrombotic microangiopathy, thrombocytopenia and acute kidney injury. Shiga toxin producing Escherichia coli (STEC) has been reported, in the majority of cases, as cause of HUS. On the other hand, pneumococcus consists a rare but important cause of HUS which, however, is frequently under-diagnosed due to its common characteristics with diffuse intravascular coagulation (DIC).

Case Report: A 2.5-year-old boy was admitted in the paediatric ward after presenting fever and cough for the last seven days. The child was treated with IV ceftriaxone-vancomycin due to lobular pneumonia with pleural effusion that was revealed in the clinical and paraclinical tests.

On day 2 of hospitalisation the boy presented a general impairment accompanied by lethargy and hemodynamic instability. The patient was transferred in the Intensive Care Unit where acute renal injury (Urea = 199mg / dL, Crea = 1.5mg / dL), thrombocytopenia and severe anemia (ΗgB=4,9gr/dL) were found. The diagnosis of HUS was suggested. Despite the intravenous rehydration and the use of diuretics, further renal failure (anuria, creatinine increase) was observed, so the patient was placed in continuous renal substitution (CVVHD). The antibiotic treatment was changed to cefotaxime, ticarcillin and clarithromycin doses were adjusted to renal function. Moreover, sessions of plasmapheresis took place in order to improve the final outcome.

Streptococcus of pneumonia (serotype 19Α) was isolated as a reaction of polymerase carried out in the pleural fluid. The clinical image of the patient got progressively improved and he was discharged from the hospital on day 20 of his hospitalisation, with normal

Conclusion: HUS and DIC may be difficult to differentiate from each other because both may involve hemolytic anemia, thrombocytopenia, and renal injury or failure. HUS from pneumococcus consists a rare disease with poor outcome and its diagnosis demands high level of suspicion. Vaccination and appropriate antibiotic treatment remain the most powerful weapon for pediatrists in order to prevent the severe complications of invasive pneumonococcal infections.