Invasive Streptococcus Pneumoniae infection Associated with Hemolytic Uremic Syndrome in Chinese Pediatric Patients

Hemolytic uremic syndrome (HUS) associated with pneumococcal pneumonia is rarely reported in the Western literature, in contrast to classical HUS associated with Escherichia coli (E. coli) (O157:H7). We conducted a retrospective review over a 2-year period from 2006 to 2008 in a large tertiary teaching hospital. Five cases were identified. All patients were Chinese children with a median age of 3 years (range: 2 – 4 years). No documented case of E. coli (O157:H7) infection was seen in the same hospital over the past 5 years from 2003 to 2008. Streptococcus pneumoniae (S. pneumoniae) infection was confirmed by positive blood and/or pleural fluid culture. Four of 5 patients developed empyema requiring decortication. HUS was diagnosed as early as 3 days after onset of febrile illness and was apparent within 2 weeks in all patients. The mean nadir for hemoglobin and platelet was 41 g/L (range: 13 – 55 g/L) and 7 ×10⁹/L (range: 4 – 9 ×10⁹/L), respectively. None of them had significant bleeding. All patients received red cell transfusion and 4 of 5 patients received platelet transfusion for prophylaxis or for coverage of invasive procedures. T activation on red cells was documented in all cases. Washed red cells and concentrated pooled platelet-rich plasma were transfused, except for 1 case when transfusion took place before a diagnosis of HUS was made. All patients had impaired renal function as evident by a raised serum creatinine level (range: 101– 756 umol/L). Only 1 patient required dialysis. One patient deteriorated rapidly and died of refractory septicemic shock and multi-organ failure 30 hours after admission. Her hemoglobin and platelet on admission was 106 g/L and 115 ×10⁹/L, respectively. She received unwashed red cells and ordinary platelet concentrate upon clinical deterioration. Blood smear examination and T activation study subsequently confirmed a diagnosis of S. pneumoniae associated HUS. All surviving patients had full renal and hematological recovery with a median follow up of 11 months (range: 3 – 28 months). Invasive S. pneumoniae infection is a relatively common association in Chinese pediatric patients with HUS. This condition can be fatal in the acute state but the medium to long term prognosis is favorable. Transfusion of washed red cells and plasma-reduced platelets is a routine practice in this group of patients, although the efficacy and necessity of this practice has not been formally studied.