Correspondence

Pneumococcal Appendicitis in a Man with HIV Infection

N Engl J Med 1993; 328:1282April 29, 1993

Article

To the Editor:

Patients infected with HIV have increased susceptibility to infection with Streptococcus pneumoniae. A 28-year-old man with hemophilia A was recently admitted to our hospital with a two-day history of malaise, sweats, and pain in the right lower quadrant. He was infected with HIV and had a CD4+ cell count of 390 per cubic millimeter. He received one dose of clindamycin and gentamicin before being taken to the operating room, where a gangrenous appendix measuring 6 by 3 cm was removed. Treatment with imipenem was begun, and the patient recovered uneventfully. Cultures of blood were negative. The intraoperative cultures yielded a heavy growth of S. pneumoniae serogroup 19. Anaerobic plates showed no growth. A probable contaminant, propionibacterium species, was isolated only from a broth culture. Pathological examination revealed acute appendicitis with a necrotic appendiceal wall; a tissue Gram's stain demonstrated gram-positive cocci.

Perforating gangrenous appendicitis is rarely a unimicrobial process. One study reported an average of 10.2 different organisms per specimen; Bacteroides fragilis and Escherichia coli were isolated most commonly1. S. pneumoniae may cause spontaneous peritonitis in children with the nephrotic syndrome and secondary hypogammaglobulinemia2. In adults, there are rare reports of spontaneous or secondary peritonitis caused by S. pneumoniae3.

HIV-infected patients are at an increased risk for pneumococcal pneumonia and pneumococcal bacteremia4. Most HIV-positive patients with pneumococcal bacteremia present with pneumonia (89 percent); however, there have been reports of pneumococcal meningitis, sinusitis, pericarditis, endocarditis, brain abscess, and mediastinitis5. Multiple defects in immunity have been demonstrated in these patients, including low base-line levels of IgG to pneumococcal polysaccharide. It has been suggested that patients with pneumococcal bacteremia be evaluated for HIV infection, especially in the absence of other underlying diseases.

We have not found other reports of appendicitis caused by S. pneumoniae. This presentation underscores the vulnerability of HIV-infected patients to infection with this organism.

Jennifer A. Clark, M.D.
Mark A. Keroack, M.D.
University of Massachusetts Medical Center, Worcester, MA 01655

5 References

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   Gorensek MJ, Lebel MH, Nelson JD. Peritonitis in children with nephrotic syndrome. Pediatrics 1988;81:849-856
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   Redd SC, Rutherford GW III, Sande MA, et al. The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents. J Infect Dis 1990;162:1012-1017
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   Janoff EN, Breiman RF, Daley CL, Hopewell PC. Pneumococcal disease during HIV infection: epidemiologic, clinical, and immunologic perspectives. Ann Intern Med 1992;117:314-324
   Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Susan Shoshana Weisberg. (2007) Pneumococcus. Disease-a-Month 53:10, 495-502
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2. 2

   Nimer Assy, Osamah Hussein, Abdallah Khalil, Anthony Luder, Sergio Szvalb, Melia Paizi, Gadi Spira. (2007) The Beneficial Effect of Aspirin and Enoxaparin on Fibrosis Progression and Regenerative Activity in a Rat Model of Cirrhosis. Digestive Diseases and Sciences 52:5, 1187-1193
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3. 3

   Cathy A. Petti, S.‐H. Ignatius Ou, Daniel J. Sexton. (2002) BRIEF REPORT: Acute Terminal Ileitis Associated with Pneumococcal Bacteremia: Case Report and Review of Pneumococcal Gastrointestinal Diseases. Clinical Infectious Diseases 34:10, e50-e53
   CrossRef

4. 4

   DANIEL D. DUGI, DANIEL M. MUSHER, JILL E. CLARRIDGE, ROBERT KIMBROUGH. (2001) Intraabdominal Infection due to Streptococcus pneumoniae. Medicine 80:4, 236-244
   CrossRef

5. 5

   EMILIO BOUZA, PATRICIA MUÑOZ. (1995) Penicillin-Resistant Pneumococci in Adult Disease with Special Reference to AIDS Patients. Microbial Drug Resistance 1:1, 9-28
   CrossRef

6. 6

   (1993) More on Pneumococcal Appendicitis. New England Journal of Medicine 329:19, 1428-1428
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