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Cláudia Silva1, Gabriela Pereira2, Rita Carneiro3, Maria João Brito1

1. Unidade de Infecciologia Pediátrica, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa
2. Unidade de Cuidados Intensivos Pediátricos, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa
3. Departamento de Imagiologia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa

- Portuguese Journal of Pediatrics; 2019, 50, 130:1 (artigo).

Eleven-month old baby girl, previously healthy, with fever, rhinorrhea, and dry cough was diagnosed with flu-like syndrome. On day 11 of the disease, she was admitted with grunting, tachypnea, and tachycardia. Hemoglobin was 8.7g/dL, leukocytes 14,160 cells/µL, 90% neutrophils, C-reactive protein 523 mg/L, and the chest X-ray showed bilateral consolidation and left pleural effusion. She was vaccinated with two doses of 13-valent pneumococcal polysaccharide conjugate vaccine. The polymerase chain reaction in throat swab was positive for influenza A H3N2 virus. She was started on oseltamivir and amoxicillin/clavulanic acid. The ultrasound revealed a 25 mm pleural empyema. A thoracoscopic debridement of the pleural space was performed and antibiotherapy was switched to ceftriaxone and vancomycin. Booth blood and pleural effusion cultures were negative but pleural fluid polymerase chain reaction identified Streptococcus pneumoniae serotype. On the seventh day of hospitalization, there was clinical worsening with respiratory distress and hypoxemia. Chest computed tomography scan revealed bilateral necrotizing pneumonia and loculated pneumothorax communicating with subcutaneous tissue. Seven days later, she presented with left tension pneumothorax with mediastinal shift with a bronchopleural fistula requiring chest drainage for 21 days. She presented progressive clinical improvement and was discharged after 39 days of hospitalization. At one year of follow-up, she is clinically well, and immunodeficiency was excluded. Influenza virus causes high morbidity and mortality. Much of the mortality is attributed to secondary bacterial pneumonia, particularly by Streptococcus pneumoniae. Serotype 3 produces higher levels of capsular polysaccharide compared to other serotypes, which explains its greater virulence. Conjugate vaccines were a milestone in reducing invasive pneumococcal disease. However, vaccination does not seem to have the same impact on the decrease of serotype 3 as in other vaccine serotypes, and the clinical relevance of this fact in the induction of long-term immune memory is unknown.

Palavras-chave: Coinfection; infant; influenza A vírus; H3N2 subtype; Orthomyxoviridae infections/complications; pneumococcal infections/complications.