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Year : 2001  |  Volume : 19  |  Issue : 2  |  Page : 59-61

Unimicrobial appendicitis due to non-vaccine serotype of streptococcus pneumoniae: Implications for and management and prevention

Department of Surgery (VNM, KS), JIPMER, Pondicherry - 605 006, India

Correspondence Address:
Department of Surgery (VNM, KS), JIPMER, Pondicherry - 605 006, India

 ~ Abstract 

The aetiology of appendicitis is usually polymicrobial. We report a rare case of appendicitis caused by Streptococcus pneumoniae as the only causative organism. The case assumes significance because it occurs in the absence of any predisposing factor for invasive pneumococcal infection, it is unimicrobial, it may lead to the misdiagnosis of primary peritonitis due to pneumococcus, and it undermines the efficacy of polyvalent pneumococcal vaccine.

How to cite this article:
Bhattacharya S, Kanungo R, Natarajan M K, Mahalakshmi V N, Srinivasan K. Unimicrobial appendicitis due to non-vaccine serotype of streptococcus pneumoniae: Implications for and management and prevention. Indian J Med Microbiol 2001;19:59-61

How to cite this URL:
Bhattacharya S, Kanungo R, Natarajan M K, Mahalakshmi V N, Srinivasan K. Unimicrobial appendicitis due to non-vaccine serotype of streptococcus pneumoniae: Implications for and management and prevention. Indian J Med Microbiol [serial online] 2001 [cited 2020 May 30];19:59-61. Available from:

The aetiology of appendicitis is usually polymicrobial,[1]  Escherichia More Details coli and Bacteroides fragilis are the commonest aerobes and anaerobes respectively[2]. Here we present a case of unimicrobial appendicitis due to Streptococcus pneumoniae.

 ~ Case Report Top

The present case relates to a 12 year male child presenting with a history of right lower abdominal pain and fever for 5 days. On general physical examination the patient was found to have tachycardia (92/min) and a blood pressure of 130/80 mm Hg. The respiratory system was found to be normal. Abdominal examination revealed rebound tenderness over the McBurney's point. There was neither organomegaly nor was there any free fluid in the peritoneal cavity, and there was no finding suggestive of spontaneous bacterial peritonitis. Biochemical profile revealed a blood urea of 40 mg/dL, blood glucose of 81 mg/dL, serum creatinine of 1.0 mg/dL and serum sodium and potassium levels to be 137 meq/L and 4.78 meq/L respectively.
Ultrasonography of the abdomen revealed a tubular hypoechoic structure seen in the right iliac fossa suggestive of an inflamed appendix 6x3x3x cm and a 4x3 cm area of collection present in the pericaecal region.
An ultrasound guided aspiration was done from the region of pericaecal abdominal collection. Microscopical examination of the aspirated pus revealed gram positive diplococci. Culture of the pus resulted in pure growth of draughtsman colonies on blood agar and characteristic colonies with bleaching on chocolate agar. There was no growth on MacConkey agar. Anaerobic culture of the specimen did not yield any obligate anaerobes. The organism was identified as Streptococcus pneumoniae by standard procedures.[2] It was found to be sensitive to Penicillin (MIC < 0.06 g/mL), Cefotaxime, Ampicillin, Ciprofloxacin, Gentamicin, Chloramphenicol and Erythromycin. The strain was untypable by Pneumotest kit (From Statens Serum Institut, Copenhagen, Denmark) containing antisera to the 23 serotypes in the polyvalent pneumococcal vaccine.
The abdomen was opened by transverse right lower quadrant muscle splitting incision. Per-operatively, appendix was found to be inflamed, enlarged and covered with omentum. The caecum was not inflamed. Periappendicular pus collection of ~ 10 mL was present. The omental adhesions were released and appendicectomy was performed. Peritoneal lavage given. The patient withstood the procedure well and was put on injection Ampicillin 300 mg i.v. 6 hourly, injection Gentamicin 30 mg i.v. 8 hourly and Metronidazole infusion 175 mg i.v.8 hourly. The patient subsequently had an uneventful recovery.

 ~ Discussion Top

Till July, 1999, only 11 cases of appendicitis due to Streptococcus pneumoniae were reported in the world. [3] The common predisposing features were HIV infection and hemophilia A.[3] In the present case there was no risk factor for invasive pneumococcal disease like splenectomy, steroid use, diabetes mellitus, intravenous drug use, connective tissue disorder or alcoholism. [3] This is consistent with the findings of Rahav et al, who in 1997, reported that only 24% of the children with invasive pneumococcal infection had an underlying disease.[4] There was also no history of past pneumococcal infection in this child in the form of otitis media, sinusitis or other respiratory tract infections (like pneumonia).
Streptococcus pneumoniae is a common cause of primary peritonitis. [3] Most of them are associated with nephrotic syndrome, liver disease and genital tract disease. Perforation of an infected appendix may be contributing factor to this entity. Timely surgical intervention in appendicitis may, therefore prevent pneumococcal peritonitis.
Unimicrobial appendicitis is rare. Bennion et al in a review in 1990 reported that the frequency of bacteria isolated from cases of gangrenous and perforated appendicitis ranged from 0.8 - 2 for aerobes (mean = 1.2), 0.4 - 2.9 for anaerobes (mean = 0.9), and 1.4 - 4.8 for aerobes and anaerobes combined (mean = 2.1). [1] Similarly Brook et al in 1980 reported 1.4 aerobes/specimen and 3 anaerobes/specimen in cases of perforated appendix in children. [2] Ronchetto et al in 1993 in a study of 43 intra operative samples of appendicular pus had only 7 cases of unimicrobial infection. Streptococcus pneumoniae were isolated in 2 cases but always in association with  Escherichia More Details coli and Bacteroides fragilis. [5]
Twenty five to 50% of the children are colonized in their throat with Streptococcus pneumoniae. [6] Failure of the non-specific local defense mechanisms due to viral infection, malnutrition or irritant gases may lead to haematogenous dissemination of pneumococci. A surveillance study in South Carolina had shown that 160 individuals per 100,000 infants and children developed pneumococcal bactereamia. [7] Although bacteraemia in this child was not confirmed by blood culture, we suspect that hematogenoous spread may have been the most probable source for the appendicitis.
This infection was caused by non-vaccine (untypable) serotype of Streptococcus pneumoniae. In populations where the incidence of nonvaccine strains of pneumococcal infections are relatively high, the efficacy of the vaccine would be relatively low.[8] According to the CDC formula,[9]
Vaccine efficacy (E) = 1 - ad/bc, where
a = disease due to vaccine strain in vaccinated
b = disease due to non-vaccine strain in vaccinated
c = disease due to vaccine strain in non-vaccinated
d = disease due to non-vaccine strain in non-vaccinated.
It is obvious from the above equation that the efficacy of a pneumoccal vaccine is inversely related to the number of cases due to non-vaccine strains in non-vaccinated. Therefore, periodic surveillance of the pneumoccal strains in a population group is imperative for the success of any meaningful vaccination strategy. 

 ~ References Top

1.Bennion RS, Barron EJ, Thompson JE, Downes J, Summjanen P, Talan DA, Finegold SM. The bacteriology of gangrenous and perforated appendicitis - revisited. Ann Surg 1990;211:165-71.  Back to cited text no. 1    
2.Brook I. Bacterial studies of peritoneal cavity and postoperative surgical wound drainage following following perforated appendix in children. Ann Surg 1980; 192: 208-12.  Back to cited text no. 2    
3.Taylor SN, Sanders CV. Unusual manifestations of invasive pneumococcal infection. Am J Med 1999; 107(14):12S-24S.  Back to cited text no. 3    
4.Rahav G, Toledano Y, Engelhard D, Simhon A, Moses AE, Sacks T, Shapiro M. Invasive pneumococcal infections. A comparison between adults and children. Medicine 1997; 76(4): 295-303.  Back to cited text no. 4    
5.Ronchetto F, Pistono PG. More on pneumococcal appendicitis. N Engl J Med 1993; 329: 1428.  Back to cited text no. 5    
6.Teele DW. Pneumococcal infections. In: Feigin RD, Cherry JD (eds). Text book of pediatric infectious diseases. Edn.4. Vol.1:W.B.Saunders Company, Philadelphia 1998; pp 1129-36.  Back to cited text no. 6    
7.Breiman RF, Spika JS, Navaro VJ, Dounden PM, Darby CP. Pneumococcal bacteremia in Charleston County, South Carolina, A decade later. Arch Intern Med 1990; 150: 140-5.   Back to cited text no. 7    
8.Hager HL, Woolley TW, Berk SL. Review of recent pneumococcal infections with attention to vaccine and non-vaccine serotypes. Rev Infect Dis 1990; 12(2): 267-72.  Back to cited text no. 8    
9.Broome CV, Facklam RR, Fraser DW. Pneumococcal disease after pneumococcal vaccination : an alternative method to estimate the efficacy of pneumococcal vaccine. N Engl J Med 1980; 303: 549-52.  Back to cited text no. 9    
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