eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pneumococcal Infections: Differential Diagnoses & Workup

Author: Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine
Coauthor(s): Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital; Nancy A Wick, MD, Consulting Staff, Department of Emergency Medicine, Section of Pediatrics, Children's at Scottish Rite; Chandy C John, MD, MS, Director, Center for Global Pediatrics, Associate Professor of Pediatrics and Medicine, University of Minnesota Medical School
Contributor Information and Disclosures

Updated: Aug 18, 2009

Differential Diagnoses

Arthritis, Septic
Mastoiditis
Bacteremia
Meningitis, Bacterial
Empyema
Osteomyelitis
Endocarditis, Bacterial
Otitis Media
Fever in the Toddler
Pericarditis, Bacterial
Fever in the Young Infant
Pneumococcal Bacteremia
Fever Without a Focus
Pneumonia
Lymphadenitis
Sinusitis

Workup

Laboratory Studies

The following studies are indicated in patients with pneumococcal infections:

  • WBC count
    • Elevated WBC count and differential showing a high band count or left shift may suggest bacterial infection.
    • Young children with a WBC count greater than 15,000 cells/mL and/or an absolute band count greater than 1500/mcL have an increased likelihood of occult bacteremia.
    • WBC count may be low in children with meningitis and other severe pneumococcal infections.
  • Antigen tests
    • The use of CSF and urine antigen tests for pneumococci is limited because of the multitude of S pneumoniae serotypes and the poor sensitivity of the test. At present, these tests should be used only in children in whom blood and CSF cultures were obtained after antibiotic treatment. In these children, antigen test results occasionally are positive when culture results are negative.
    • A negative result on an antigen test does not exclude pneumococcal infection.
  • Gram stain
    • Gram stains of usually sterile body fluids (CSF, synovial fluid, pleural fluid) showing gram-positive diplococci strongly suggest the diagnosis of pneumococcal infection, although alpha-hemolytic streptococci and group B streptococci can look like S pneumoniae.
    • Results of CSF Gram stains in younger children with meningitis are positive 90-100% of the time, but the CSF Gram stain technique may be slightly less sensitive in older children.
  • Culture
    • Culture of S pneumoniae from usually sterile body fluids (eg, blood, CSF, pleural fluid, middle ear effusion, synovial fluid) establishes the diagnosis definitively.
    • Perform susceptibility testing when an invasive infection is present.
  • For each of the following clinical syndromes, specific testing recommendations are as follows:
    • Otitis media or sinusitis
      • Tympanocentesis and bacterial cultures of middle ear fluid should be performed in children with chronic otitis media refractory to antibiotic treatment. This requires technical expertise.
      • Sinus fluid should be obtained and sent for bacterial culture if the sinusitis is refractory to antibiotic treatment.
      • Upper respiratory tract cultures are not reliable in determining infection because of the high rate of asymptomatic children carrying S pneumoniae.
    • Occult bacteremia - Blood culture of sufficient volume (minimum of 2 mL)
  • Pneumonia
    • Sputum cultures are difficult to obtain from children, and results may be falsely positive because of the high rates of upper respiratory colonization in this population.
    • Blood cultures should be obtained in all patients, although only 25-30% of patients with pneumococcal pneumonia have positive results on blood culture.
  • Meningitis
    • When meningitis is suspected, lumbar puncture should be performed. CSF should be sent for cell count, protein levels, glucose levels, Gram stain, and culture. Antigen tests are needed only if the patient was pretreated with antibiotics.
    • A blood culture also should be obtained to further confirm the diagnosis and the pathogens.
  • Osteomyelitis/septic arthritis
    • Procedures include surgical biopsy or joint aspiration; fluid or bone is cultured for the organism.
    • Perform blood culture, since bacteremia often is present as well.

Imaging Studies

  • Chest radiographs may reveal lobar or segmental consolidation or typical findings of round pneumonia.
  • In many centers, a head CT scan is performed in older children with meningitis to exclude increased intracranial pressure prior to performing lumbar puncture. No compelling evidence exists that CT findings are better than physical examination at predicting complications from lumbar puncture, and, in most patients, a CT scan causes unnecessary delay of lumbar puncture. In young children with an open fontanelle, a head CT scan is unnecessary unless physical findings suggest complications or a diagnosis other than meningitis. In children with persistent fevers despite appropriate antimicrobial therapy, a head CT scan, or preferably an MRI, should be performed to exclude subdural empyema. MRI is more sensitive than CT in the detection of subdural or epidural empyema.

Procedures

  • Lumbar puncture

More on Pneumococcal Infections

Overview: Pneumococcal Infections
Differential Diagnoses & Workup: Pneumococcal Infections
Treatment & Medication: Pneumococcal Infections
Follow-up: Pneumococcal Infections
Multimedia: Pneumococcal Infections
References
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References

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Further Reading

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Keywords

pneumococcus, Streptococcus pneumoniae, S pneumoniae, pediatric infections, otitis media, osteomyelitis, septic arthritis, pericarditis, peritonitis, pneumococcal disease, pneumococcal pneumonia, pneumococcal infection, invasive pneumococcal disease, IPD, HIV infection, agammaglobulinemia, complement deficiency, splenectomy, sickle cell anemia, nephrotic syndrome, chronic renal failure, organ transplantation, immunosuppressive therapy, chronic pulmonary disease, cerebral spinal fluid leak after skull fracture, cochlear implant, diabetes mellitus, malignancy, otalgia, cough, meningitis

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Contributor Information and Disclosures

Author

Meera Varman, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Infectious Diseases, Creighton University School of Medicine
Meera Varman, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: phamaceutical companies Honoraria Speaking and teaching; phamaceutical companies Grant/research funds clinical trials

Coauthor(s)

Archana Chatterjee, MD, PhD, Professor of Pediatrics, Medical Microbiology and Immunology, and Pharmacy, Division of Pediatric Infectious Diseases, Chief of Division of Pediatric Infectious Diseases, Creighton University School of Medicine; Hospital Epidemiologist and Medical Director of Infection Control, Children's Hospital
Archana Chatterjee, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, International Society for Infectious Diseases, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: GlaxosmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi-Pasteur Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; GlaxoSmithKline Grant/research funds Other; MedImmune  Other; Merck Grant/research funds Other; Novartis Grant/research funds Other; Sanofi-Pasteur Grant/research funds Other

Nancy A Wick, MD, Consulting Staff, Department of Emergency Medicine, Section of Pediatrics, Children's at Scottish Rite
Nancy A Wick, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chandy C John, MD, MS, Director, Center for Global Pediatrics, Associate Professor of Pediatrics and Medicine, University of Minnesota Medical School
Chandy C John, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

David Jaimovich, MD, Chief Medical Officer, Joint Commission International and Joint Commission Resources
David Jaimovich, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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