Hemolytic uremic syndrome associated with pneumococcal pneumonia in Taiwan

Abstract

Streptococcus pneumoniae ( S. pneumoniae ) has been associated with hemolytic uremic syndrome (HUS), which is an unusual but serious disease in childhood. We conducted a retrospective review of children aged less than 18 years with S. pneumoniae -associated HUS in northern Taiwan from January 2000 to June 2005. The demographic characters, clinical courses, and outcomes were analyzed. Seven children (three girls, four boys) with S. pneumoniae -associated HUS were studied. The median age at onset of HUS was 40 months (range: 25-60 months). The median duration of hospital stay was 36 days (range: 15-50 days). The interval between the onset of illness attributable to S. pneumoniae and the development of HUS was around 1-2 weeks. The onset of oliguria developed within 2 weeks after illness. Six patients required dialysis with median duration of 16 days. Three patients had leukopenia as the initial presentation. All seven patients had pneumococcal pneumonia complicating with empyema, and two of them received decortication via video-assisted thoracoscopic surgery. Between patients who needed dialysis or not, there was no significant difference in age, sex, duration of thrombocytopenia, incidence of extra-renal complications, such as hepatitis, pancreatitis, and hypertension, and length of hospital stay. The seven patients survived with normal renal function. HUS is a potentially fatal complication of S. pneumoniae infection. Clinicians managing patients with pneumococcal pneumonia with empyema accompanied by leukopenia should beware of the development of HUS. The long-term prognosis for recovery of renal function appears to be good in these patients in northern Taiwan.

Streptococcus pneumoniae-associated hemolytic uremic syndrome

“…Features of pneumococcal HUS usually develop 3 to 13 days (most at 7 to 9 days) after the onset of pneumococcus-related symptoms [19,38]. This chronology is similar to that described for Shiga-like toxin-producing E. coli-associated HUS (STEC HUS), in which diarrheal illness typically occurs 7 days (range 1-14 days) prior to the onset of HUS [43].…”

“…Since 1987, 73 children [14,16,18,19,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] with pneumococcal HUS have been reported in the English language literature. Of these, 12.3% (9/73) died; 10.1% (7/69) progressed to ESRF; and 16% (11/69) survived, with chronic kidney disease or hypertension.…”

“…The improved mortality rate in the past 20 years may have been the result of the advances in critical care medicine as opposed to changes in disease virulence [31]. A careful analysis of the 69 children with comprehensive clinical data [14,16,18,19,[22][23][24][25][26][27][28][29][30][31][32][34][35][36][37][38] reveals that only 28% of the patients presented with meningitis. However, 88% of the deaths occurred in this subgroup (clinical data available on 8/9 patient deaths).…”

“…The estimated mortality rate of pneumococcal meningitis in children without HUS is 8-10% [50], while the mortality rate in patients with pneumococcal meningitis complicated by HUS is 37% (7/19) [16,22,23,26,[29][30][31]34]. In marked contrast, pneumococcal HUS not associated with meningitis has a mortality rate of only 2% [14,16,18,19,22,[24][25][26][27][28][29][30][31][32][34][35][36][37][38].…”

“…They also have longer periods of oligo-anuria, more frequent need for acute dialysis (75% vs 59%), longer hospital stays (33 days vs 16 days), more red blood cell and platelet transfusions, and a longer duration of thrombocytopenia [31]. In our review of the 73 patients reported from 1987 to 2007 [14,16,18,19,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] 10.1% developed endstage renal failure (ESRF) and 12.3% died in the acute phase. These rates are two-to-three-times higher than those of STEC HUS [43,44,45].…”