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Streptococcus suis meningitis in swine worker in Larissa, Greece
E.Sogka¹ F.Koumoutsou¹ O.Triantafyllou¹ N. Aggelis¹ V.Lalos¹ S.Karamaggiolis¹ K. Karamitsos¹
1 Department of Internal Medicine, General Hospital of Larissa. Larissa , Greece
•Streptococcus suis is a zoonotic pathogen.
•It is found in the upper airway, reproductive system, and digestive
tracts of pigs -without causing disease -and in pork derived products.
•Human S. suis infections are most often reported from countries
where pig-rearing is common (figure 1). The relative high mean
patient age (47-55 years) and almost complete absence of children in
case series, as well as the high male-to-female patient ratio (3.5:1.0
to 6.5:1.0) support the notion that infection with S. suis is generally an
occupational disease
•Meningitis is the most common clinical syndrome. Sepsis,
endocarditis, arthritis are other common manifestations.
Figure 1
CASE REPORT
A previously healthy 34 –year old Indian man, presented with fever,
chills and severe headache unresponsive to paracetamol. The
symptoms had been present for the past 3 days.
No past medical history
The patient is employed as a pig breeder for the past 2 years, hasn’t
traveled abroad recently and doesn’t smoke or drink alcohol.
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EXAMINATION
General appearance: patient looks weak and tired
Skin: jaundice (icteric conjunctiva of the eyes), no rash, no open
wounds
Airway and breathing: Patent airway, spontaneously breathing,
clear to percussion and auscultation bilaterally, RR 18, Saturation
99% on air
Cardiovascular: regular rate and rhythm with no murmurs or
friction rub. HR 80min, AP 110/60 mmHg, ECG SR
Abdomen: non-distended , soft, no significant tenderness, liver and
spleen are non palpable ,bowel sounds present,.
Neurological examination: GCS 15/15, neck stiffness, partial
unilateral hearing loss
BLOOD ANALYSIS
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Anemia normocytic
Raised inflammation Markers: Neutrophilic leycocytosis,
High fibrinogen ( 890.00 mg/dl) and high CRP (30.7)
Abnormal liver function: SGOT 54IU/L, SGPT 62IU/L,
TOTAL BILLIRUBIN 1.62mg/dl, DIRECT BILLIRUBIN
0.72mg/dl, normal INR
IMAGING
Meningitis
DIFFERENTIAL DIAGNOSIS
Encephalitis Tetanus
Dengue fever
Subarachnoid hemorrhage
Malaria
INITIAL APPROACH
Steps to diagnosis:
– Fundoscopy: no signs of raised ICP ( Figure2 )
– CT scan : no abnormal findings
– Blood Culture
– Lumber puncture : analysis and culture ( Table 1)
Figure 2
CSF findings
Normal Values
Appearance
Slight turbid
Clear
Cell rount
476/mm^3
<5/mm^3
Predominant Cell
95% polymorphs
Lympocytes
Glucose
1mg/dl
Protein
213mg/dl
40–80 mg/dL (< 40% of simultaneously measured
plasma level if that plasma level is abnormal)
15-60mg/L
Gram staining
Negative
Negative
Table 1
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DIAGNOSIS – EMPIRIC TREATMENT
Based on the CSF analysis the diagnosis of Bacterial
Meningitis was confirmed. Empiric treatment with
ceftriaxone and vancomycin was started immediately .
Dexamethasone was administered for the first 4 days.
PROCEDURES
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Blood and urine culture
Procalcitonin
HIV Serology
WRIGHT agglutination test for Brucella
Leptospira Serology
Mantoux
Toxoplasma Serology
Daily examination of renal and liver function, electrolytes and
inflammation markers.
FINAL DIAGNOSIS
On the 3rd day of the patient’s hospitalization, STREPTOCOCCUS
SUIS was isolated from blood and CSF samples. The
empiric treatment continued due to appropriate sensitivity of
the serotype to both ceftriaxone and vancomycin.
HOSPITAL COURSE
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Despite the simultaneous use of dexamethasone and antibiotics, partial
unilateral hearing loss persisted .Brain MRI was performed in order to
identify involvement of the labyrinth. The result was negative. ( Figure 4).
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Subsequent blood cultures were negative. There were no other
complications.
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The case was reported to HCDCP*.
FOLLOW -UP
Patient was discharged/released after 10 days of hospitalization, with no
complications other than the partial unilateral hearing loss. We
recommended the continuation of antibiotics per os and a review/followup visit/reassesment in 2 week as an outpatient.
* HCDCP: Hellenic center of disease control and prevention (keelpno.gr)
Figure 4
Figure 4
CONCLUSIONS
•Meningitis is the most common clinical manifestation of S. suis infection and the presenting features of meningitis are generally similar to those of other
types of bacterial pyogenic meningitis.
•Although it can be cultured from CSF or blood samples with the aid of standard microbiological techniques, it is often misidentified or even
undiagnosed. In patients presenting with meniningitis, S. suis should be considered regardless of the patient’s occupational backround if the
characteristic features of prominent and early hearing loss are present.
•Increased awareness among clinicians and appropriate education of people who handle pigs or pork –derived products are needed so that they
appreciate the importance of S. suis as a human pathogen.
REFERENCES
•Heiman F. L. Wertheim, Ho Dang Trung Nghia, Walter Taylor and Constance Schultsz: S. Suis an emerging human pathogen, EMERGING INFECTION, CID 2009:48 (1
March)
•Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 7, July 2014
•Seong-Min Choi, Bang-Hoon Cho, Kang-Ho Choi, Tai-Seung Nam, Joon-Tae Kim, Man-Seok Park, Byeong C. Kim, Myeong-Kyu Kim, Ki-Hyun Cho, Meningitis Caused by
Streptococcus suis: Case Report and Review of the Literature, J Clin Neurol 2012;8:79-82
•Guillaume Goyette-Desjardins, Jean-Philippe Auger, Jianguo Xu, Mariela Segura and Marcelo Gottschalk, Streptococcus suis, an important pig pathogen and emerging
zoonotic agent—an update on the worldwide distribution based on serotyping and sequence typing, Emerging Microbes and Infections (2014) 3
•The Merk Manuals, Streptococcus Suis infection, Last full review/revision March 2014 by Marcelo Gottschalk, DVM, PhD
•Epidemiology of bacterial meningitis in adults, UPTODATE, Literature review current through: Nov 2014