Journal of Medical Microbiology (2004), 53, 83–84 DOI 10.1099/jmm.0.

05338-0

Case Report Severe community-acquired pneumococcal

pneumonia (CAP) – a potentially fatal illness
Martin Gerard Kelly,† Rose A. Sharkey, Kenneth W. Moles and J. Gerard Daly

Department of Respiratory Medicine, Ward 3, Altnagelvin Area Hospital, Glenshane Road, Derry,
Correspondence
Co. Londonderry BT47 6AB, Northern Ireland, UK
Martin Gerard Kelly
martin.kelly@chmeds.ac.nz
Two cases of severe community-acquired pneumococcal pneumonia (CAP) admitted to our hospital
within 24 h are described, both in young males. These two cases illustrate the usefulness of the
British Thoracic Society severity criteria and serve to emphasize the importance of early recognition
of adverse physiology in critically ill patients. We should not lose sight of the continued impact of
pneumonia in this climate of widespread fear about severe acute respiratory syndrome (SARS).
Received 5 June 2003
Accepted 5 September 2003

Introduction
In recent months, both the British Medical Journal (Zambon
& Nicholson, 2003) and the New England Journal of Medicine
(Drazen, 2003; Tsang et al., 2003) have commented exten-
sively, quite rightly in our opinion, on the new severe acute
respiratory syndrome (SARS). Epidemiologically, virologi-
cally and clinically, this is a fascinating disorder, attracting
the attention of the World Health Organization (WHO,
2003). However, whilst one of the authors (M. G. Kelly) was
recently visiting Singapore, he was struck by the high profile
engendered by this disease in the media and by the use of
facemasks by the general public, particularly in Changi
airport. In contrast, countless numbers of cases of commun-
ity-acquired pneumococcal pneumonia (CAP) often go by
unnoticed and unpublicized. Indeed, these too may be
severe, life-threatening or even fatal (British Thoracic Society
Standards of Care Committee, 2001).
In our hospital, we have recently encountered a number of
cases of CAP in young, fit males aged 20–45. Two particular
cases, occurring within 24 h of each other, serve to remind us
of the continuing significance of this condition, the useful-
ness of the British Thoracic Society severity score (the CURB
score) and, particularly, the role of pneumococcal infection
(British Thoracic Society Standards of Care Committee,
2001; Lim et al., 2001).
Case 1
A healthy 22-year-old male welder, who had smoked 20
†Present address: Canterbury Respiratory Research Group, Hagley
Building, Christchurch Hospital, Private Bag 4710, Christchurch 8001,
Canterbury, New Zealand.
Abbreviations: CAP, community-acquired pneumococcal pneumonia;
SARS, severe acute respiratory syndrome.
Downloaded from www.microbiologyresearch.org by
05338 & 2004 SGM Printed in Great Britain IP: 36.68.76.193
On: Sat, 11 Aug 2018 12:41:26
cigarettes per day for 5 years, was admitted with a 4 day flu-
like illness, characterized by dry cough, anorexia and anergia
followed 24 h prior to admission by fever and rigors.
Clinical examination revealed a relatively undistressed male
with a tachycardia (120 beats min 1 ), tachypnoea (40
breaths min 1 ), hypotension (80/40 mmHg), fever (39.4
8C) and desaturation (O2 saturation 85 % breathing room
air). He was clammy, sweaty and vasodilated and had
dullness with coarse inspiratory crackles at the left base.
Chest radiograph confirmed extensive left lower lobe con-
solidation. Electrocardiograph confirmed sinus tachycardia.
Arterial blood gas breathing room air revealed a mixed
pattern of respiratory failure [pH 7.31 (normal range 7.35–
7.45), pO2 4.09 kPa (10–13), pCO2 6.0 kPa (4.5–6.0),
bicarbonate 26 mmol l 1 (22–28), base excess +1.6 ( 2.0
to +2.0)] with a mixed acidosis. Haematological investiga-
tion revealed leucopenia (white cell count 2.4 with neutro-
phils 2.03109 cells l 1 ). Biochemistry revealed acute renal
failure [urea 30.3 mmol l 1 (normal range 3–7), creatinine
342 ìmol l 1 (normal range 30–110)]. C reactive protein
(CRP) was elevated, at 246 mg l 1 (normal range , 5). Day
1 blood cultures grew penicillin-sensitive (but macrolide-
resistant) pneumococcus. Aggressive colloid and crystalloid
resuscitation corrected the hypovolaemia, with good im-
provement in renal function. Intravenous coamoxiclav and
oral erythromycin were instituted. Despite high-flow oxy-
gen, ward-based continuous positive airway pressure re-
spiratory support and a change of antibiotics, this patient
required intensive care unit admission and ventilation 48 h
after admission. He required prolonged invasive ventilation
(25 days) and, eventually, a tracheostomy for adult respira-
tory distress syndrome (ARDS). After 2 weeks in intensive
care, the patient was discharged to the ward, where he
rehabilitated rapidly to recover from his critical illness
polyneuropathy and was eventually discharged home. At
review 6 weeks later, he was well and radiological changes
had resolved.
83
M. G. Kelly and others
Case 2
Twenty-four hours after the first admission, a 22-year-old
male alcoholic, a smoker with a history of sociopathic
personality traits and evidence of substance misuse, was
admitted in a toxic confusional state. A corroborative history
suggested a recent dry cough. He had been ‘living rough’. On
examination, he was unkempt, cachexic, confused in time
and place, aggressive and clinically dehydrated. He had a
tachycardia (120) and tachypnoea (24) but was afebrile and
normotensive. Oxygen saturations breathing room air were
92 %. Glasgow Coma Scale was 13/15. Pupils were widely
dilated, equal and reactive. Extensive bronchial breath
sounds were heard over the right hemithorax, but only a
few coarse inspiratory crackles. Chest radiograph revealed
right lower lobe consolidation and pleural effusion with
lingular and left lower lobe consolidation. Arterial blood gas
measurement breathing room air confirmed type-1 respira-
tory failure with respiratory alkalosis [pH 7.478 (normal
range 7.35–7.45), pO2 8.86 kPa (10–13), pCO2 4.24 kPa
(4.5–6.0), bicarbonate 24 (22–28), base excess +0.4 ( 2.0 to
+2.0). Sodium was 118 mmol l 1 , but urea and creatinine
were normal. White cell count was normal and CRP was
100 mg l 1 . Treatment was instituted with both intravenous
coamoxiclav and clarithromycin. Crystalloid infusion was
commenced and oxygen administered. This patient required
one-to-one ratio nursing and boluses of short-acting benzo-
diazepines to manage his illness initially. He improved well,
and the purulent, blood-stained sputum he was expectorat-
ing cultured penicillin-sensitive pneumococcus. He devel-
oped a complicated right parapneumonic effusion that has
failed to resolve, despite intercostal ultrasound-guided
insertion of a small-bore drain, and the patient has been
referred to thoracic surgeons for further management of this
complication, as he has a restrictive lung defect as a
consequence with functional impairment.
Discussion
Case 1 had a CURB score of 3/4 [raised urea (.7.0 mmol l 1 )
and respiratory rate (.30 breaths min 1 ) and low blood
pressure (systolic <90 and/or diastolic <60 mmHg)] and
case 2 had a score of 1/4 (confusion). Increasing CURB score
has been demonstrated to be associated with increasingly
adverse outcome, particularly death (British Thoracic So-
ciety Standards of Care Committee, 2001; Lim et al., 2001).
The clinical course of each patient’s illness reflected these
scores, with case 1 having a more critical course.
Although rare, previously well young adults do die from
CAP. Simpson et al. (2000) found that 5 % of all cases of CAP
in young adults aged 15–44 years in England and Wales
involved just such patients and that Streptococcus pneumo-
niae was the commonest identifiable causative organism. In-
Downloaded from www.microbiologyresearch.org by
84 IP: 36.68.76.193
On: Sat, 11 Aug 2018 12:41:26
hospital management of cases was felt to be generally
adequate. Awareness of the potential for critical illness in
this population and prompt antimicrobial therapy were felt
to be key issues in improving outcome.
Overall mortality from hospitalized CAP has been demon-
strated to range between 4 and 14 % (British Thoracic Society
Standards of Care Committee, 2001; Lim et al., 2001; Hug &
Rossi, 2001). This is comparable with SARS (Drazen, 2003;
Tsang et al., 2003) but, of course, SARS has been demon-
strated to be highly infective to close contacts, particularly
healthcare workers (Drazen, 2003; Tsang et al., 2003;
Zambon & Nicholson, 2003). Nonetheless, in this time of
increased alertness towards unusual respiratory pathogens, it
is important that the more usual presentations of CAP are
still recognized. These can cause severe respiratory illness,
causing significant morbidity and mortality, yet respond well
if recognized and treated promptly. Indeed, early recognition
of severely ill patients and their consequent deterioration is
often poor (Buist et al., 2002), yet objective triggers such as
severity scores may be important in triggering a response.
These cases demonstrate such points well.
References
British Thoracic Society Standards of Care Committee (2001). BTS
guidelines for the management of community acquired pneumonia in
adults. Thorax 56 (Suppl. 4), IV1–IV64.
Buist, M. D., Moore, G. E., Bernard, S. A., Waxman, B. P., Anderson, J. N.
& Nguyen, T. V. (2002). Effects of a medical emergency team on
reduction of incidence of and mortality from unexpected cardiac arrests
in hospital: preliminary study. BMJ 324, 387–390.
Drazen. J. M. (2003). Case clusters of the severe acute respiratory
syndrome. N Engl J Med 348, e6–e7.
Hug, B. & Rossi, M. (2001). A year’s review of bacterial pneumonia at the
central hospital of Lucerne, Switzerland. Swiss Med Wkly 131, 687–692.
Lim, W. S., Macfarlane, J. T., Boswell, T. C. J., Harrison, T. G., Rose, D.,
Leinonen, M. & Saikku, P. (2001). Study of community acquired
pneumonia aetiology (SCAPA) in adults admitted to hospital: implica-
tions for management guidelines. Thorax 56, 296–301.
Simpson, J. C. G., Macfarlane, J. T., Watson, J. & Woodhead, M. A.
(2000). A national confidential enquiry into community acquired
pneumonia deaths in young adults in England and Wales. British
Thoracic Society Research Committee and Public Health Laboratory
Service. Thorax 55, 1040–1045.
Tsang, K. W., Ho, P. L., Ooi, G. C. & 13 other authors (2003). A cluster of
cases of severe acute respiratory syndrome in Hong Kong. N Engl J Med
348, 1977–1985.
WHO (2003). Update 27 – One month into the global SARS outbreak:
status of the outbreak and lessons for the immediate future. Mounted
online 11 April 2003. http://www.who.int/csr/sarsarchive/2003_04_11/
en/
Zambon, M. & Nicholson, K. G. (2003). Sudden acute respiratory
syndrome. BMJ 326, 669–670.
Journal of Medical Microbiology 53