The most common and serious form of pneumococcal disease is the lung infection, pneumococcal pneumonia. Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain [1] [5].

Classic symptoms of pneumococcal pneumonia are typically observed in older children and adults, while young children and the elderly will present differently (discussed later) [1]. Infected patients typically have an ill or anxious appearance [1]. Initially a viral illness is followed by an acute onset of high fever, rigors, productive cough, chest pain, dyspnea, tachypnea, tachycardia, excess perspiration, general discomfort and fatigue [1] [5]. A detailed physical exam will identify rales in most patients, dullness on percussion (along with other signs of empyema) and splinting due to pain in about half of patients. Decreased diaphragmatic motion from what is expected (considering tachypnea) may be observed [1].

Symptoms of pneumococcal pneumonia in younger children are generally much broader and non-specific compared to older children and adults [1] [5] [8] [9]. These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia [1] [9]. Young patients may also present emesis which suggests primary gastrointestinal disease, meningeal signs due to meningeal irritation (in right upper lobe pneumonias), and/or chest pain due to pleural irritation [1] [9]. The primary presenting symptom of pneumococcal pneumonia in elderly patients may be tachypnea and often elevated temperatures are absent or mild in this patient population [1] [8] [9]. The most common cause of CAP in human immunodeficiency virus (HIV) patients is pneumococcus infection [1].

Pleural effusion is the most common complication from pneumococcal pneumonia occurring in 40% of patients [1]. Only 10% of patients have enough fluid in their pleural cavity to aspirate and only 2% of these patients meet the criteria for true empyema [1] [5]. Nonetheless, pneumococcal infection is one of the most common causes of pediatric empyema [1] [8] [9].

• Fever

  The number of study subjects with fever and blood leucocytosis of >17.5 × 10E9/L at one to 36 months of age was 202. [ncbi.nlm.nih.gov]

  Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain. [symptoma.com]

  […] sinustitis, fever and pain in the face. [healthychildren.org]

  Bloodstream infections typically have non-specific symptoms including fever and irritability. Children with otitis media typically have a painful ear. Other symptoms that may accompany otitis media include sleeplessness, fever and irritability. [nfid.org]

• Chills

  Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13® should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13® or any diphtheria toxoid–containing [adult.prevnar13.com]

  Some of its symptoms appear suddenly and may include chest pain and difficulty breathing, a high fever, shaking chills, excessive sweating, fatigue, and a cough with phlegm that persists or gets worse. [knowpneumonia.com]

  Common symptoms of pneumococcal pneumonia include fever and chills, cough, hyperventilation, difficulty breathing and chest pain. [symptoma.com]

  High age, alcoholism, chills, pleuritic chest pain, a leukocyte count of greater than 15 x 10(9)l and an elevated CRP were factors significantly more common among those with pneumococcal pneumonia than among the MP patients. [ncbi.nlm.nih.gov]

  Symptoms Fevers, body-shaking chills, productive cough, pleurisy, prostration, and sweating. [medical-dictionary.thefreedictionary.com]

• High Fever

  Symptoms include high fever, and loss of appetite, stiff neck, headache, vomiting, fussiness (crying), difficulty waking up (drowsiness). Meningitis can cause seizures, deafness or brain damage. [caringforkids.cps.ca]

  Symptoms typically come on quickly and may include difficulty breathing, shortness of breath, chest pain, high fever, excessive sweating and shaking chills, and coughing. [lung.org]

  These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia. [symptoma.com]

  Some of its symptoms appear suddenly and may include chest pain and difficulty breathing, a high fever, shaking chills, excessive sweating, fatigue, and a cough with phlegm that persists or gets worse. [knowpneumonia.com]

• Fatigue

  Some of its symptoms appear suddenly and may include chest pain and difficulty breathing, a high fever, shaking chills, excessive sweating, fatigue, and a cough with phlegm that persists or gets worse. [knowpneumonia.com]

  Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13® should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13® or any diphtheria toxoid–containing [adult.prevnar13.com]

  Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms.[1] Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur. [en.wikipedia.org]

• Anemia

  All of them were acutely ill on presentation with arterial desaturation, and they developed anemia and thrombocytosis. Two patients had pleural effusion requiring drainage. [ncbi.nlm.nih.gov]

  Sepper Roxadustat Treatment for Anemia in Patients Undergoing Long-Term Dialysis N. Chen et al. Roxadustat and Anemia of Chronic Kidney Disease J. Kaplan Roxadustat for Anemia in Patients with Kidney Disease Not Receiving Dialysis N. Chen et al. [nejm.org]

  It usually strikes smokers, people with underlying lung diseases, those recently infected with influenza or those with sickle-cell anemia, chronic or heavy alcohol use, or cirrhosis. [medical-dictionary.thefreedictionary.com]

• Cough

  Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur. [symptoma.com]

  This is what causes pneumococcal pneumonia symptoms such as chest pain, coughing, and difficulty breathing. symptoms Symptoms Pneumococcal pneumonia can come on quickly. [knowpneumonia.com]

  The person then develops a high fever, chills, and cough with sputum. [medicalnewstoday.com]

  This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia. [ncbi.nlm.nih.gov]

• Pleural Effusion

  High C-reactive protein (CRP) (≥20 mg·dL(-1)) (odds ratio (OR) 2.36, 95% CI 1.45-3.85), pleural effusion (OR 2.03, 95% CI 1.13-3.65) and multilobar involvement (OR 1.69, 95% CI 1.02-2.79) were independently associated with bacteraemic CAP, while nursing [ncbi.nlm.nih.gov]

  effusion (90%) Pneumatocoele In adults Patchy bronchopneumonia of segmental distribution, frequency bilateral May be associated with atelectasis since airways are filled (not so with pneumococcal) Pleural effusion (50%) Most common in winter Only 5% [learningradiology.com]

• Dyspnea

  A 36-year-old pregnant woman was visiting the emergency department for dyspnea and flu-like syndrom that had been going on for a week. [ncbi.nlm.nih.gov]

  Pneumonia is diagnosed by clinical symptoms, including cough, dyspnea and tachypnea, and radiologic evidence. [symptoma.com]

  The clinical presentation of pnuemococcal pneumonia includes fever, cough and malaise and may also include chest pain and dyspnea or tachypnea. Streptococcus Pneumonia is a gram positive diplococci. [radiopaedia.org]

  It is characterized by progressive dyspnea, cyanosis, tachypnea, and tachycardia. [jamanetwork.com]

• Productive Cough

  This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia. [ncbi.nlm.nih.gov]

  Chest infection (pneumonia) can present with fever, shortness of breath, chills and productive cough. It may result in death in severe cases. Infection of the brain membranes (meningitis) can present with fever, stiff neck and confusion. [chp.gov.hk]

  In adults, symptoms of pneumonia include sudden onset of illness characterized by shaking chills, fever, shortness of breath or rapid breathing, chest pain that is worsened by breathing deeply and a productive cough. [nfid.org]

  Symptoms Fevers, body-shaking chills, productive cough, pleurisy, prostration, and sweating. [medical-dictionary.thefreedictionary.com]

• Painful Cough

  This is what causes pneumococcal pneumonia symptoms such as chest pain, coughing, and difficulty breathing. symptoms Symptoms Pneumococcal pneumonia can come on quickly. [knowpneumonia.com]

  Symptoms to look for generally include: Fever and chills Headache Ear pain Cough Chest pain Shortness of breadth Disorientation Occasionally a stiff neck Symptoms occur generally within 1 to 3 days, but this time period is not definite. [phpa.health.maryland.gov]

  It’s spread through the air by coughing and sneezing. [health.govt.nz]

• Vomiting

  Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13® should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13® or any diphtheria toxoid–containing [adult.prevnar13.com]

  Symptoms include high fever, and loss of appetite, stiff neck, headache, vomiting, fussiness (crying), difficulty waking up (drowsiness). Meningitis can cause seizures, deafness or brain damage. [caringforkids.cps.ca]

  The classic symptoms may be difficult to detect in infants and the child may only appear to be inactive, irritable, feeding poorly and may be vomiting. [sahealth.sa.gov.au]

• Nausea

  Other symptoms like nausea, vomiting, headache, fatigue, and muscle aches could also accompany the original symptoms.[1] Sometimes the coughing can produce rusty or blood-streaked sputum. In 25% of cases, a parapneumonic effusion may occur. [en.wikipedia.org]

  Additional symptoms, such as nausea, vomiting, muscle aches, and fatigue may also be observed Administration of antibiotics is the standard treatment for Pneumococcal Pneumonia, with the symptoms starting to clear in healthy individuals within 48-72 hours [dovemed.com]

  You may first have a severe shaking chill which is usually followed by: High fever Cough Shortness of breath Rapid breathing Chest pains Other symptoms may include: Nausea Vomiting Headache Tiredness Muscle aches Diagnosis Your healthcare provider can [medicinenet.com]

  Symptoms can include: sore ear(s), hearing loss and fever (middle ear infection) sore face, blocked nose, headaches and a yellow-green mucus (sinus infection) high fever, headache, nausea, vomiting, stiff neck and coma (brain and spinal cord infection [health.gov.au]

• Loss of Appetite

  Symptoms include high fever, and loss of appetite, stiff neck, headache, vomiting, fussiness (crying), difficulty waking up (drowsiness). Meningitis can cause seizures, deafness or brain damage. [caringforkids.cps.ca]

  Mild-to-moderate problems: PPSV23 Redness or pain where the shot was given Fever, muscle aches, and drowsiness PCV13 Redness, swelling, pain or tenderness where the shot was given Fever, loss of appetite, irritability, drowsiness, headache and chills [walgreens.com]

  Symptoms include: 3 5 6 Stiff neck Fever and headache Sensitivity to light Confusion Vomiting Rash In babies, meningitis may cause loss of appetite, low alertness and vomiting. [gskpro.com]

  Risks of a vaccine reaction Redness, swelling, pain, or tenderness where the shot is given, and fever, loss of appetite, fussiness (irritability), feeling tired, headache, and chills can happen after PCV13. [medlineplus.gov]

• Abdominal Pain

  These symptoms may include mild respiratory symptoms, initial presentation of cough, tachypnea, dyspnea, splinting, high fever, abdominal pain and distention and/or anorexia. [symptoma.com]

  Thirty-nine percent appeared generally unwell, vomiting was present in 47 % and abdominal pain in 28%. Respiratory auscultation detected rales in 30 % of the patients, hypophonesis in 28 % and polypnea or dyspnea in 35 %. [analesdepediatria.org]

• Chest Pain

  Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur. [symptoma.com]

  This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia. [ncbi.nlm.nih.gov]

  This is what causes pneumococcal pneumonia symptoms such as chest pain, coughing, and difficulty breathing. symptoms Symptoms Pneumococcal pneumonia can come on quickly. [knowpneumonia.com]

  The clinical presentation of pnuemococcal pneumonia includes fever, cough and malaise and may also include chest pain and dyspnea or tachypnea. Streptococcus Pneumonia is a gram positive diplococci. [radiopaedia.org]

• Cyanosis

  The characteristic clinical picture is one of progressive respiratory distress and cyanosis, with relatively few physical findings pertaining to the thorax. [ajronline.org]

  It is characterized by progressive dyspnea, cyanosis, tachypnea, and tachycardia. [jamanetwork.com]

  […] pneumococcal infection are: born with certain immune deficiencies receiving certain drugs or radiation treatment people who have no spleen or whose spleen does not work properly HIV infection chronic renal (kidney) failure Down's Syndrome heart disease causing cyanosis [health.nsw.gov.au]

  […] that usually worsens when taking a deep breath, known as pleuritic pain fast heartbeat fatigue and weakness nausea and vomiting diarrhea sweating headache muscle pain confusion or delirium, especially in older adults dusky or purplish skin color, or cyanosis [medicalnewstoday.com]

  Additional findings in children with severe disease include cyanosis, nasal flaring, and intercostal retractions. [emedicine.medscape.com]

• Hypotension

  Adrenal insufficiency and re- sponse to corticosteroids in hypotensive critically ill children with cancer. J Crit Care 2012;27:480–7. Article information Continued © 2016 Soonchunhyang Medical Research Institute [jsms.sch.ac.kr]

  In brief, all patients received empiric antimicrobial therapy as early as possible and concordant with the National Guidelines, and fluid resuscitation with intravenous crystalloids for patients with hypotension. [pneumonia.biomedcentral.com]

• Myalgia

  Other symptoms do include nausea, vomiting, headache, myalgia, and overall fatigue. In normal, healthy adults Pneumococcus infects one or more parts of the lung, and thus is called lobar pneumonia. [austincc.edu]

  History may reveal signs and symptoms such as fatigue, weight loss, myalgia/arthralgia, rash, and headache, which may point to an undiagnosed and underlying HIV infection. [ncbi.nlm.nih.gov]

  Myalgia and diarrhea were more common among BPP outpatients and inpatients than in non-BPP patients. [journals.lww.com]

• Meningism

  Abstract An extended-spectrum cephalosporin has been considered appropriate therapy for non-meningeal infections caused by drug-resistant Streptococcus pneumoniae. [ncbi.nlm.nih.gov]

  There are vaccines available to help protect against pneumococcal meningitis, find out more here. Been affected by pneumococcal meningitis? Don’t face meningitis alone. Contact our helpline on 0808 80 10 388 to speak to our experienced staff. [meningitisnow.org]

  INVASIVE PNEUMOCOCCAL DISEASE• Bacteremia most common clinical presentation among children younger than 2 years• Most common cause of bacterial meningitis in the U.S.• Highest rate of meningitis among children younger than 2 yearsDR.T.V.RAO MD 14 15. [slideshare.net]

  Bacterial meningitis: Pneumococcal meningitis infections cause more than 50% of all bacterial meningitis cases in the U.S. About 8% of children and 22% of adults with pneumococcal meningitis will die. Middle ear infections. [health.ny.gov]

• Headache

  Other side effects include: fatigue muscle pain joint pain chills headache vomiting decreased appetite rash fever PREVNAR 13® should not be given to anyone with a severe allergic reaction to any component of PREVNAR 13® or any diphtheria toxoid–containing [adult.prevnar13.com]

  Symptoms can include: sore ear(s), hearing loss and fever (middle ear infection) sore face, blocked nose, headaches and a yellow-green mucus (sinus infection) high fever, headache, nausea, vomiting, stiff neck and coma (brain and spinal cord infection [health.gov.au]

  Symptoms include high fever, and loss of appetite, stiff neck, headache, vomiting, fussiness (crying), difficulty waking up (drowsiness). Meningitis can cause seizures, deafness or brain damage. [caringforkids.cps.ca]

  Early symptoms can include a high fever plus a severe headache or a stiff neck. Information on early warning signs is available on the NHS Choices website .) [aidsmap.com]

• Confusion

  Symptoms include: Fever and chills Cough Rapid breathing or difficulty breathing Chest pain Older adults with pneumococcal pneumonia may experience confusion or low alertness, rather than the more common symptoms listed above. [cdc.gov]

  Symptoms include: Confusion or disorientation Shortness of breath High heart rate Fever, shivering, or feeling very cold Extreme pain or discomfort Clammy or sweaty skin Pneumococcus bacteria cause up to half of middle ear infections (otitis media). [health.hawaii.gov]

  Depending on what organ or part of the body is infected, pneumococcal disease will cause any of several serious illnesses, including: Bacterial meningitis, an infection of the covering of the brain and spinal cord that can lead to confusion, coma, and [webmd.com]

  The symptoms of pneumococcal meningitis include stiff neck, fever, mental confusion and disorientation, and sensitivity to light. [adolescentvaccination.org]

• Altered Mental Status

  mental status, findings consistent with consolidationon physical exam, and leukocyte count > 12,000/ mm3 [17]; having had testing for the detection of SPUAT and blood cultures during their initial microbiological evaluation at admission. [pneumonia.biomedcentral.com]

  mental status 39 (9.8) 49 (10) 0.9 Pulse ≥ 125/min 62 (15.6) 62 (12.6) 0.2 Respiratory rate ≥ 30/min 98 (24.8) 96 (19.5) 0.06 Systolic blood pressure 30 (7.5) 42 (8.5) 0.6 Temperature 7 (1.8) 4 (0.8) 0.2 Laboratory findings on admission Blood urea nitrogen [bmcpulmmed.biomedcentral.com]

  BAL may be used in patients who are unable to cooperate with an induced sputum sample (eg, because of altered mental status). BAL may be less useful in cases of suspected PJP relapse. Consultation with a pulmonologist is required for BAL. [emedicine.medscape.com]

• Agitation

  A 30-year-old confirmed body packer was brought to our emergency department from jail because of agitation and mydriasis. [ncbi.nlm.nih.gov]

  […] spleen that does not function Symptoms usually come on quickly, and may include: Fever and chills Mental status changes Nausea and vomiting Sensitivity to light ( photophobia ) Severe headache Stiff neck Other symptoms that can occur with this disease: Agitation [m.medlineplus.gov]

Diagnosing pneumococcal pneumonia most often starts by establishing the presence of pneumonia [1]. Pneumonia is diagnosed by clinical symptoms, including cough, dyspnea and tachypnea, and radiologic evidence [1] [5]. Representative chest radiographs in older children and adults with pneumococcal pneumonia show lobar consolidation while younger children and infants more often display patterns of scattered parenchymal consolidation [1] [5] [9]. Sputum Gram staining and culture are also primary steps for diagnosing pneumonia [1] [3] [5].

The gold standard to determine pneumococcal pneumonia is by identifying S. pneumoniae in a normally sterile body fluid [3] [5]. In suspected pneumonia cases that require hospitalization, sputum cultures should be attempted [1]. Suitable sputum samples should have a few epithelial cells (<10 at 100X) and many polymorphonuclear neutrophils (>25 at 100X) with a ratio between 1:10 and 1:20 [3] [5]. The presence of pneumococcus is likely if Gram staining of sputum reveals numerous pairs of Gram-positive cocci organized in chains (characteristic of S. pneumoniae) [3] [4] [5]. Blood cultures should be obtained from patients with pneumonia, which will stain positive for S. pneumoniae in 10% of children and up to 25% of adults with pneumococcal pneumonia [1] [3] [5]. Chest ultrasonography or computerized tomography may be performed to determine the presence and extent of pleural effusion [1]. In extreme cases of pleural effusion/empyema, attempts should be made to aspirate pleural fluid for Gram staining and culture of S. pneumoniae [1] [3] [5].

The majority of patients with pneumococcal pneumonia present leukocytosis (>12,000 cells/µL) and one out of four patients have low hemoglobin levels (<10 mg/dL) [1] [5]. If Howell-Jolly bodies are observed in peripheral smears this indicates splenic dysfunction [1]. Additionally, pneumococcal pneumonia patients may display elevated neutrophil levels, C-reactive protein (CRP) levels and erythrocyte sedimentation rate (ESR) [1] [5].

• Pulmonary Infiltrate

  This may be the first report of the association of these two disorders, and may influence the choice of antibiotic selection in patients with rhabdomyolysis and a pulmonary infiltrate. [ncbi.nlm.nih.gov]

  The roentgen findings are those of diffuse, granular pulmonary infiltrates which progress from the hili toward the periphery of the lung, becoming more and more confluent. [ajronline.org]

• Air Bronchogram

  bronchograms (black branching structures) present since the spaces surrounding the air-filled bronchi normally contain air but now are filled with inflammatory exudate. [learningradiology.com]

  Radiographic appearances considered classic for pneumoccocal pneumonia include lobar consolidations and air bronchograms in adults and round pneumonia in children however this type of pneumonia can have many different appearances 1,2. [radiopaedia.org]

  According to classic radiologic descriptions, a lobar pattern of consolidation was considered present in the setting of homogeneous confluent air-space density, with or without associated findings of air bronchograms or the presence of acinar shadows [ajronline.org]

• Neutrophilia

  Seventy-eight percent had WBC counts > 15,000 and 93 % showed neutrophilia of > 60%. Erythrocyte sedimentation rate and C-reactive protein were elevated in 77 % and 85 % of the patients, respectively. [analesdepediatria.org]

  They induce intra-pleural neutrophilia and fibrin formation in pleura (26). In summary, S. pneumoniae is a coccus bacterium which causes pneumococcal disease. [content.sciendo.com]

• Streptococcus Pneumoniae

  A case of pneumonia caused by Streptococcus pneumoniae occurring in a patient receiving pristinamycin is reported. Despite empirical treatment with pristinamycin, 2 g/day for five days, the patient's condition worsened. [ncbi.nlm.nih.gov]

  (disorder) [Ambiguous] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia] Streptococcus pneumoniae pneumonia Streptococcus pneumonia edit English pneumococcal pneumonia human disease Chest infection - pneumococcal pneumonia Lobar -pneumococcal [wikidata.org]

  Fig. 4 Modes of person-to-person transmission of Streptococcus pneumoniae Fig. 5 Simplified description of serious Streptococcus pneumoniae infections, with a focus on initial respiratory tract disease. [pneumonia.biomedcentral.com]

• Blood Culture Positive

  We aimed to compare characteristics of patients with blood-culture-positive versus blood-culture-negative pneumococcal CAP, and to characterise bacteraemic serotypes.We describe a prospective, observational study on nonimmunocompromised patients with [ncbi.nlm.nih.gov]

  Bacteremic pneumococcal pneumonia was defined as having a blood culture positive for pneumococcus, and non-bacteremic was defined as having a sputum culture positive for pneumococcus and/or a positive Binax UAT without a blood culture positive for pneumococcus [journals.plos.org]

  All patients with a diagnosis of CAP and at least 1 positive blood culture for S pneumoniae taken within 48 hours of presentation to the hospital were included in the analysis. [jamanetwork.com]

• Gram-Positive Coccus

  Streptococcus pneumoniae is a Gram-positive coccus that may be found in pairs or in short chains. Lobar Pneumonia involves large portion of a lobe or an entire lobe of the lung. [histopathology-india.net]

  Gram positive coccus (usually seen as diplococci with a distinctive “lancet shape”. Belongs to the alpha hemolytic "viridans” streptococci. b. [web.biosci.utexas.edu]

• Pneumococcus in Blood Culture

  Bacteremic pneumococcal pneumonia was defined as having a blood culture positive for pneumococcus, and non-bacteremic was defined as having a sputum culture positive for pneumococcus and/or a positive Binax UAT without a blood culture positive for pneumococcus [journals.plos.org]

• Gram-Positive Bacteria

  Streptococcus pneumoniae, or pneumococcus, is a gram-positive bacteria responsible for many types of pneumococcal infections. [news-medical.net]

• Pleural Effusion

  High C-reactive protein (CRP) (≥20 mg·dL(-1)) (odds ratio (OR) 2.36, 95% CI 1.45-3.85), pleural effusion (OR 2.03, 95% CI 1.13-3.65) and multilobar involvement (OR 1.69, 95% CI 1.02-2.79) were independently associated with bacteraemic CAP, while nursing [ncbi.nlm.nih.gov]

  effusion (90%) Pneumatocoele In adults Patchy bronchopneumonia of segmental distribution, frequency bilateral May be associated with atelectasis since airways are filled (not so with pneumococcal) Pleural effusion (50%) Most common in winter Only 5% [learningradiology.com]

• Pleural Exudate

  (ii) In outer surface pleural exudates is thicker. (iii) Cut surface is moist & brownish-gray colour (bronchial lymphnodes may be enlarged). [histopathology-india.net]

Severity and presentation of symptoms among patients with pneumococcal pneumonia vary widely, from mild illness to respiratory distress requiring intensive care [1] [5]. Hospitalized patients should be administered parenteral antibiotics along with medications to manage nutrition and symptoms, including pulmonary symptoms, pain medications, intravenous (IV) fluids and nutrition, and other medications administered on a case by case basis [1] [5] [13] [14] [15]. Severe and/or complicated cases may require a chest tube to drain pleural fluid, video-assisted thoracoscopic surgery (VATS) or decortication [13] [14] [15]. New Clinical Practice Guidelines (CPG) for infants and children were released by the Infectious Disease Society of America (IDSA) in 2011 [14]. Briefly, these guidelines recommend IV administration of amoxicillin (90 mg/kg/day or 45 mg/kg/day in 2 or 3 doses, respectively) as the first-line therapy for previously healthy and immunized patients from the infant to adolescent ages with mild to moderate pneumococcal pneumonia [14]. Additionally, children greater than 5 years of age should be administered macrolide if clinical symptoms are compatible with atypical organism infection [14]. Children who are incompletely immunized, live in areas with prevalent penicillin resistance or who have life threatening conditions (including empyema) should be given third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) [14]. If there is a suspicion of S. aureus infection non-beta-lactam agents, such as vancomycin, should also be administered [14].

Worldwide, pneumococcal disease caused an estimated 1.6 million deaths in 2005, with the majority of these deaths (40-60%) occurring in young children (less than 5 years of age) [5] [6] [7]. The mortality rate associated with pneumococcal pneumonia is 10-20% in adults, even in developed countries, and can be much higher in individuals with risk factors for this disease, such as compromised immune system, smoking and drug use [5] [7].

S. pneumoniae is an encapsulated, Gram-positive, catalase-negative, facultative anaerobe that displays characteristic chains of lancet-shaped diplococcic on Gram stains [1] [2] [3]. Along with Gram staining, pneumococcus can be detected on blood or chocolate agar plates where they form a green zone around colonies due to the production of pneumolysin (making them hemolytic) [2] [3] [4] [5]. These organisms can be distinguished from other alpha-hemolytic streptococci based on their optochin-sensitivity and bile solubility [5].

S. pneumoniae, which is the leading cause of CAP, is responsible for approximately two million deaths worldwide and costs hundreds of billions of dollars annually [5]. Worldwide, children under the age of two are the most common individuals to contract pneumococcal disease, followed by adults older than 55 years of age [5] [6] [7]. Disease prevalence in developing countries is higher in children under 6 months of age, whereas, developed countries have higher incidence in children between 6 months and 1 year or age [5] [6] [7]. Most studies indicate males have a higher prevalence of pneumococcal infection compared to females [5]. Certain ethnic groups in the United States have higher incidence of invasive pneumococcal disease including, native Alaskans, Navajo and Apache Indians, and African Americans [5] [6] [7]. The reasons for these discrepancies remain unclear. Individuals with suppressed immune systems have a higher risk for contracting pneumococcal disease [5] [6] [7].

S. pneumoniae is an extracellular bacterial pathogen that can be found in the nose and throat of 5-10% and 20-40% of healthy adults and children, respectively [1] [3] [5]. Clinical manifestation in patients requires S. pneumoniae to access and colonize the upper and/or lower respiratory tract, which occurs via direct extension, lymphatic spread or hematogenous spread [1]. In healthy individuals under normal conditions, successful clearance mechanisms (anatomic and ciliary) prevent clinical infection/symptoms [1]. Therefore, pathogenicity involves bacterial adhesion proteins and capsule proteins that allow adherence to host cells, escape from clearance and/or phagocytosis and the ability to replicate [1] [5] [7].

Few toxins have been identified from pneumococcal isolates aside from pneumolysin, which is expressed by all serotypes [1] [5]. Pneumolysin is an important virulence factor (classified as a cholesterol-dependent cytolysin), released by S. pneumoniae, that produces pores in host cell membranes leading to cell death [1] [5]. Additionally, pnuemolysin is a potent activator of the complement system and causes the release of inflammatory cytokines, tumor necrosis factor and interleukin-1 [5]. Other important virulence factors may include adhesion proteins, such as surface protein A and surface adhesion A, and enzymes, such as autolysin, hyaluronidase and neuraminidase [1] [5]. The composition and size of the bacterial capsule is another determinant of virulence [5]. Individuals with no previous exposure to S. pneumoniae (or no antibodies to pneumococcal capsule) display a limited immune response, including diminished phagocytosis and activation of the classical complement pathway [1] [5].

Patient symptoms primarily arise from activation of the complement pathway and robust inflammation caused by inflammatory cytokine release [1]. The alternative complement pathway is directly activated by S. pneumoniae cell wall and capsule components, whereas, the classical complement pathway is activated by antibodies to the cell wall of S. pneumoniae [1] [5]. Bacterial cell wall proteins and deoxyribonucleic acid (DNA) along with pnuemolysin and autolysin are the primary causes of inflammatory cytokine production [1].

There is an increased risk for invasive pneumococcal disease associated with cigarette smoking, therefore, smoking cessation should be encouraged [5] [10] [15]. A healthy diet and ideal living conditions may decrease disease risk and when applicable breastfeeding should be encouraged [10] [15]. Children who attend daycare have an increased risk for acquisition, carriage and infection with pneumococcal disease which is directly correlated with the number of children that attend a daycare [10]. Doctors may consider antimicrobial prophylaxis for at risk patients with recurrent otitis media [10]. Children with true anatomical or functional asplenia should be administered prophylaxis with penicillin to help prevent pneumococcal disease [5] [10] [15].

S. pneumoniae is a member of the genus Streptococcus that is characterized by being Gram-positive, catalase-negative, alpha-hemolytic and anaerobic [1]. Along with being the most common cause of community-acquired pneumonia (CAP), S. pneumoniae also causes bacterial meningitis, bacteremia, otitis media, sinusitis, septic arthritis, osteomyelitis, peritonitis and endocarditis [1].

Pneumococcal pneumonia is a serious condition caused by S. pneumoniae, which are easily identified in the sputum of infected individuals by their characteristic organization in Gram-positive diplococci chains. S. pneumoniae release toxins that activate the complement system and induce inflammation leading to a wide range of symptoms, that may include fever and chills, cough, hyperventilation, difficulty breathing and chest pain. An estimated two million deaths per year are caused by pneumococcal pneumonia (mortality rate ~ 10-20%) with the majority of these deaths occurring in children 5 years of age or younger. Antibiotics, such as penicillin, are typically used to treat this disease but with the emergence of resistant strains, cephalosporins, vancomycin or fluoroquinolones may be administered. Presentation of disease varies greatly and the patient’s age should be considered for diagnosis and treatment of pneumococcal pneumonia.

Pneumococcal pneumonia is a serious and sometimes life threatening disease caused by the bacteria S. pneumoniae (also known as pneumococcus) [1] [5]. This bacterium may be spread by water droplets that are released through the air when infected individuals cough or sneeze. Symptoms of pneumococcal pneumonia often arise suddenly and may include fever, chills, malaise (general discomfort), shortness of breath and a cough that produces rust colored sputum [1] [5]. Sharp stabbing chest pains on one side, which are worsened by deep breathing and cough, often occur [5]. A little less than half of patients will develop fluid accumulation in the lining around their lungs (pleural effusion) which also contributes to chest pain and difficulty breathing [5]. Your doctor will perform chest X-rays to look for pneumonia and take sputum samples to look for pathogens [1] [5]. Sputum, blood and pus samples may be sent to a laboratory to identify S. pneumoniae through growth (culture) and staining methods, which easily identify the presence of S. pneumoniae [1] [3] [5]. If bacteria are present, the effectiveness of different antibiotics can be tested through a process known as susceptibility testing [3] [4] [5].

Currently, there are two types of vaccines for S. pneumoniae available. The PCV13 is a conjugate vaccine that protects against 13 different type of pneumococcus and the PPS23 is a non-conjugate vaccine that protects against 23 different types of pneumococcus [16] [17]. Children under 5 years of age with an absent or dysfunctional spleen are often given recurrent antibiotics that may continue into adulthood [10] [13] [14]. The most common antibiotics administered for pneumococcal infections are penicillin, ampicillin and amoxicillin [5] [10]. Typically, antibiotics are given orally, however, in severe cases intravenous administration may be required [5] [10] [13]. The recent increase in penicillin resistant strains of pneumococcus has led to the use of other antibiotics, such as ceftriaxone, cefotaxime, vancomycin or fluoroquinolones (eg. levofloxacin) [11] [12].

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14. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53(7):e25-76.
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16. World Health Organization Staff. Immunization, Vaccines and Biologicals Division. Pneumococcal Vaccines. World Health Organisation. http://www.who.int/vaccines/en/pneumococcus.shtml. Published 2015. Accessed 2015.
17. World Health Organization Staff. Pneumococcal Vaccination. World Health Organization. http://www.cdc.gov/pneumococcal/vaccination.html. Published 2015. Accessed 2015.