Gettysburg Medical News
 The Clinical View
 by P.E. Hoffsten, MD
 7 December 2005

THAT PESKY PNEUMOCOCCUS

            Several weeks ago, this column was devoted to a problem of Legionellosis or Legionella pneumonia.  An “epidemic” identified seventeen people in Rapid City, the majority of whom had been exposed to a decorative fountain in the lobby of a restaurant.  This story made a big splash even though Legionella causes less than 1% of all the cases of pneumonia.  Fortunately, the fountain is now removed and the epidemic is over.  Of the 90,000 cases of pneumonia that occur in this country, more tan 20% are caused by pneumococcus.  This story gets little notice for some reason.  Now winter weather has come upon us and the pneumococcus is an even more prominent threat.  Examples of how ugly this bug can be are described below.

            A 75 year old gentleman with a history of heart failure was doing well.  He had had an uneventful day, and about 7:00 o’clock that night developed a shaking chill followed by a high fever to 104 degrees F°.  He was brought quickly to the emergency room where he coughed up bloody sputum.  Soon thereafter, his blood pressure dropped in spite of antibiotic treatments.  Treatment is ongoing and recovery not established yet.

            Lesson #1:  Pneumococcal pneumonia tends to strike the elderly.

            Lesson #2:  Pneumococcal pneumonia is much more common in those with heart failure and “wet lungs”.

            Lesson #3:  The onset of pneumococcal pneumonia can be devastatingly fast. 

            A one year old child developed a high fever and ceased to use the bottle.  She was brought to the emergency room where a diagnosis of pneumococcal meningitis was made.  After a prolonged hospital course, the child is recovering but probably will have some brain damage.

            Lesson #4:  Pneumonococci tend to strike the young, under age 5. 

            A healthy 45 year old office worker, somewhat overweight had a problem with sleep apnea.  Unfortunately, he was a smoker and drank coffee all day long.  About 3:00 o’clock in the afternoon one day, he had a nonspecific feeling of illness, had a shaking chill and vomited.  When he vomited, he noticed that there was some blood in the sputum that he coughed up.  He came to the emergency room and was seen to have a lobar pneumonia caused by pneumococcus.  After a four day hospitalization, and another week of antibiotics at home, he recovered and was able to return to work.

            Lesson #5:  Pneumococcal pneumonia tends to occur in those who do not clear their secretions well.  Sleep apnea is a predisposing factor in this regard.  A second factor in this gentleman was the constant coffee drinking that allowed reflux of stomach contents back into the throat and down into his lungs.

            In 1918, there was an influenza pandemic with an estimated 20 million deaths worldwide.  It is said that the cause of death in these 20 million was influenza.  In fact, most of them died of pneumococcal pneumonia as a secondary infection after influenza had weakened the person’s defensives.

            Lesson #6:  The biggest risk of influenza is a secondary pneumonia with pneumococcus or other bacteria.  Be aware we are in danger of a major influenza epidemic at this time.

            Other predisposing factors for pneumococcal pneumonia include alcoholism, cancer patients on chemotherapy, and those with a disease called multiple myeloma.  When these individuals develop a fever, it is very dangerous to say it is “just a cold” or “a little flu”.  These individuals need immediate evaluation and possibly antibiotic therapy.

            Unlike Legionella that can have a common source of spread such as the fountain in the restaurant mentioned above, pneumococci are resident in the mouths of the general public.  As long as that person’s defense mechanisms remain in place and strong, the pneumococcus does not cause disease but any of the factors mentioned above can compromise a person’s infectious disease defenses and pneumococcus can strike with devastating speed and dire consequences.  Many pneumonias are contagious but pneumococcal pneumonia  is not.

            Fortunately, there are steps that can be taken to avoid the pneumococcal infections.  One of these is the use of a pneumonia shot called Pneumovax.  People sometimes misunderstand that Pneumovax is only for the pneumococcus.  It does not all prevent pneumonias but it will decrease the likelihood of the person developing pneumococcal pneumonia.   Pneumovax injections are recommended for all adults 65 years of age and older.  If a person has had a shot of Pneumovax prior to age 65, a booster at age 65 is recommended by some agencies.  Personally, I think it is a wise step for everybody at age 65 and older to get a Pneumovax shot at least once.  Repeat injections of Pneumovax after age 65 are not useful.

            For children, it is now routine to give protection against Pneumococcus the same way we give protection against tetanus and diphtheria and polio.  The family practitioners, pediatricians, certified nurse practitioners, and physician assistants at your local clinics are well aware of the considerations for protecting children.  It is highly recommended.

            When Penicillin first came out in the 1940’s, pneumococcus was very sensitive to it and small doses of penicillin would cure the disease in people that previously died with no available treatment.  Over the past 60 years, the pneumococci in our general population have become increasingly resistant to penicillin and now it is no longer a reliable treatment for a community acquired pneumococcal pneumonia.  Other medications called fluoroquinolones are now available as both intravenous and oral preparations.  Treated early, recovery is an expected result in 95% of the people that have pneumococcal pneumonia but there is still a 5% mortality primarily related to a compromise of the person’s immune defense mechanisms.  Early diagnosis and treatment of the condition does make a difference and the healthcare providers at your local clinics are well aware of this.  We have very good antibiotics available to kill the pneumococcus but we need to get there in time.