Pneumococcal bacteremia with retropharyngeal soft-tissue inflammation and acute epiglottitis.

Abstract

Pneumococcal bacteremia secondary to acute epiglottitis is relatively rare, and all previously reported cases occurred in immunocompromised patients. We report a case of pneumococcal bacteremia associated with acute epiglottitis and retropharyngeal soft-tissue inflammation with upper airway narrowing that occurred in an otherwise healthy patient. In light of our unique finding, we recommend that pneumococcal bacteremia be suspected in an otherwise healthy patient who has systemic manifestations associated with acute epiglottitis.

Introduction

Streptococcus pneumoniae is known to cause several soft-tissue infections, including epiglottitis. (1-4) There are reports of bactcremic pneumococcal epiglottitis in immunocompromised adults. (1-3) In this article, we report a case of pneumococcal bacteremia secondary to acute epiglottitis and retropharyngeal soft-tissue inflammation in an immunocompetent adult, a finding that we believe has not heretofore been reported.

Case report

A 61-year-old black woman sought evaluation for sore throat and difficulty swallowing and breathing of 5 days' duration. She had a history of tonsillectomy and bronchial asthma, which was managed with inhalation albuterol and ipratropium bromide. She also had a history of drooling and nmcopurulent secretions. She denied any cough, fever, nasal discharge, headache, or hemoptysis. Her physical examination revealed congestion in her throat and tonsillar fossae and minimal stridor. Her temperature was 104.8 Fahrenheit. Findings on the remainder of the physical examination were unremarkable.

Indirect laryngoscopy detected an erythematous and swollen epiglottis but normal vocal folds. Her white blood cell count was 17,200/[micro]1 with a left shift. The chest radiograph was negative for any infiltrate. Computed tomography of the neck showed thickening of the epiglottis, retropharyngeal soil-tissue swelling, and compromise of the airway in the subglottic region. Two sets of blood cultures and a throat culture were performed. Because the patient was allergic to penicillin, she was started on levofloxacin and clindamycin. She was also given an intravenous corticosteroid because of her airway compromise. Her blood cultures grew penicillin-sensitive S pneumoniae, but the throat culture contained only mixed flora. Therefore, the clindamycin was discontinued. Transthoracic echocardiography failed to detect any cardiac vegetation. After the patient developed a rash, she was switched from levofloxacin to azithromycin. She gradually improved and her leukocytosis resolved. Her CD4 lymphocyte count and CD4/CD8 ratio were normal. Tests for human immunodeficiency virus infection and serum antinuclear antibodies were also negative. She was discharged in good health after 2 weeks of therapy.

Discussion

Pneumococci are a major cause of pneumonia, empyema, otitis media, septic arthritis, septicemia, and meningitis. (5) However, this organism is rarely considered in the differential diagnosis of other organ-site infections. There are limited number of case reports of infections involving the skin, fascia, tongue, epiglottis, thyroid, brain, and breast caused by this organism. (1)

Only six cases of pneumococcal epiglottitis and bacteremia have been reported, and all occurred in immunocompromised patients. (1-3) As described by DiNubile et al, two of these patients had underlying systemic lupus erythematosus. (1) DiNubile et al suggested a possible association between pneumococcal soft-tissue infections and connective tissue disease. Two other patients had multiple myeloma, which has a well-known association with defective humoral immunity. (2,3) Of the remaining two patients, one had lymphoma and one had leukemia, and they were treated with chemotherapy. (2) Our patient did not have any of these clinical conditions. Berg et al published an additional report of five cases of pneumococcal bacteremia secondary to acute epiglottitis, but they did not clearly specify any underlying conditions. (4)

The mucosal epithelium of the nasopharynx is the primary site of pneumococcal colonization. (6) Spneumoniae is known to cause infections of the middle ear, sinuses, trachea, bronchi, and lungs by direct spread of the organisms from the primary site of colonization. (5) Therefore, the involvement of the epiglottis and the retropharyngeal space in our patient can probably be attributed to the direct spread of the organisms from the previous colonization site in her nasopharynx.

The prevalence of pneumococcal disease is higher in patients with altered pulmonary clearance--for example, in those who have chronic bronchitis, asthma, or chronic obstructive lung disease. (5) Incidence is inversely related to ambient temperature; it reaches its peak during the middle of winter and is directly associated with the peak incidence of viral respiratory disease. (7) Our patient did not have a history of diabetes or alcoholism, which are also known to be more common in patients with pneumococcal disease. However, she did have a history of bronchial asthma, and her infection was diagnosed in the middle of winter. These two factors may have contributed to her acquisition of pneumococcal disease, but they do not explain why she became bacteremic.

There is no specific recommendation in the literature on the choice and duration of antibiotic therapy for bacteremic pneumococcal epiglottitis. Management guidelines established for bacteremic pneumococcal pneumonia may be used in these cases. Because of the high prevalence of penicillin-resistant pneumococci, it is reasonable to initiate an intravenous third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) or a fluoroquinolone (e.g., levofloxacin). (5) The average duration of fever is 6 to 7 days, and antibiotic therapy is generally continued until the patient is afebrile for 72 hours. (8) However, bacteremia associated with pneumococcal pneumonia is not a contraindication for switching therapy to an oral antibiotic. (9) Based on these guidelines, the total duration of therapy for a case of bacteremic pneumococcal epiglottitis should range from 10 to 14 days.

Soft-tissue infection and bacteremia caused by S pneumoniae is probably under-reported and thus its prevalence is most likely underestimated. The case of our patient indicates that bacteremia can be associated with such an infection even in the absence of an underlying immunosuppressive condition. Detection of bacteremia associated with epiglottitis influences the choice of antibiotic, the route of administration, and the duration of therapy. We conclude that pneumococcal bacteremia should be suspected in otherwise healthy patients who have systemic manifestations associated with acute epiglottitis.

Acknowledgment

The authors thank Sander Friedman, MD, former chairman of the Department of Medicine at Coney Island Hospital, for his critical review of this case report.

References

(1.) DiNubile MJ, Albornoz MA, Stumacher RJ, et al. Pneumococcal soft-tissue infections: Possible association with connective tissue diseases. J Infect Dis 1991;163:897-900.

(2.) Kessler HA, Schade R, Trenholme GM, et al. Acute pneumococcal epiglottitis in immunocompromised adults. Stand J Infect Dis 1980;12:207-10.

(3.) Gorfinkel H J, Brown R, Kabins SA. Acute infectious epiglottitis in adults. Ann Intern Med 1969;70:289-94.

(4.) Berg S, Trollfors B, Nylen O, et al. Incidence, aetiology, and prognosis of acute epiglottitis in children and adults in Sweden. Scand J Infect Dis 1996;28:261-4.

(5.) Musher DM. Streptococcus pneumoniac. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 5th ed. Philadelphia: Churchill Livingstone, 2000:2128-47.

(6.) Austrian R. Some aspects of the pneumococcal carrier state. J Antimicrob Chemother 1986;18(Suppl A):$35-45.

(7.) Kim PE, Musher DM, Glezen WP, et al. Association of invasive pneumococcal disease with season, atmospheric conditions, air pollution, and the isolation of respiratory viruses. Clin Infect Dis 1996;22:100-6.

(8.) Bartlett JG, Breiman RF, Mandell LA, File TM, Jr. Community-acquired pneumonia in adults: Guidelines for management. The Infectious Diseases Society of America. Clin Infect Dis 1998; 26:811-38.

(9.) Ramirez JA. Switch therapy in adult patients with pneumonia. Clin Pulm Med 1995:2:327-33.

From the Department of Medicine. Coney Island Hospital, Brooklyn, N.Y.

Reprint requests: Muhammad M. Zaman, MD. Department of Medicine, Coney Island Hospital, 2601 Ocean Pkwy., Brooklyn. NY 11235. Phone: [phone]; fax: [phone]; e-mail: [e-mail]