Beneath the surface: a case report on nonencapsulated Streptococcus pneumoniae-associated invasive disease in an immunocompromised patient
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Background. Streptococcus pneumoniae , a prominent human pathogen linked to various systemic diseases, includes non-typeable pneumococci marked by the absence of a detectable capsule. However, the majority of invasive infections are attributed to encapsulated strains. This case report details the first documented instance of invasive disease caused by non-typeable S. pneumoniae in Argentina since 2017.
Case Presentation. A 19-year-old woman presented with haemorrhagic injuries attributed to chronic oral mucosa irritation. Subsequent hospitalization revealed bone marrow aplasia, leading to antibiotic, antifungal, antiviral, and immunosuppressive treatments, culminating in her discharge. Two weeks later, she was readmitted with sepsis related to a respiratory focus, exhibiting a negative COVID-PCR test. After ten days, ICU admission revealed additional infections: positive COVID-PCR test, fungal sinusitis, and S. pneumoniae bacteremia. Targeted treatments led to improvement, and the patient was subsequently discharged.
S. pneumoniae characterization. Verification of the capsule’s absence utilized traditional methods such as the Quellung reaction, transmission electron microscopy, molecular assays, and Whole Genome Sequencing (WGS). The isolate, identified as ST18335, displayed genetic features and antibiotic resistance patterns, concordant between WGS and the agar dilution method. It demonstrated non-susceptibility to penicillin and cefotaxime, based on meningitis breakpoints, as well as meropenem and cotrimoxazole.
Conclusion. This case underscores the clinical significance of non-typeable S. pneumoniae , emphasizing the necessity for a comprehensive approach to identification and characterization. The findings contribute to ongoing discussions regarding the challenges posed by non-typeable strains in vaccine development, understanding clinical impacts, and addressing antibiotic resistance. As the pneumococcal epidemiological landscape evolves, this case serves as a valuable addition to the evolving knowledge surrounding non-typeable S. pneumoniae , highlighting the continued need for surveillance and research in infectious diseases.
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You have responded to all reviewer comments comprehensively.
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This is a thorough case report and will be of interest to the Access Microbiology readership. The reviewers raise points I would like you to address in a revision. Please pay particular attention to the suggestion of a new title and expanded abstract, and the recommendation to comment further on initial treatment.
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Comments to Author
Zintgraff, Sanchez Eluchans et al provide a detailed case report on an occurrence of an immunocomprised sepsis patient infected with an unencapsulated Streptococcus pneumoniae strain. They thoroughly detail the management of this complex case, as well as the extensive microbiological analyses performed on the S. pneumoniae isolate. They are able to confirm the non-typeable (NT) nature of this isolate, searching the global databases too to find no closely related strains. They end by discussing the paucity of understanding around the nature of NT S. pneumoniae strains and what role they may play in invasive pneumococcal disease. This was an excellent case report, I commend the authors for their incredibly thorough investigation into the nature of this isolate. I have four minor revisions to recommend. …
Comments to Author
Zintgraff, Sanchez Eluchans et al provide a detailed case report on an occurrence of an immunocomprised sepsis patient infected with an unencapsulated Streptococcus pneumoniae strain. They thoroughly detail the management of this complex case, as well as the extensive microbiological analyses performed on the S. pneumoniae isolate. They are able to confirm the non-typeable (NT) nature of this isolate, searching the global databases too to find no closely related strains. They end by discussing the paucity of understanding around the nature of NT S. pneumoniae strains and what role they may play in invasive pneumococcal disease. This was an excellent case report, I commend the authors for their incredibly thorough investigation into the nature of this isolate. I have four minor revisions to recommend. Firstly, the title should be altered to make clear this is a case report of a single invasive infection from a nonencapsulated pneumococcus. At the moment it comes across as a title for a review article. Secondly, I would make the abstract slightly longer, incorporating a sub-section briefly outlining the details of the case and another subsection on the outcome of the investigations. Thirdly, through-out the text the location is often referred to as "our country" or "our region" I would replace this with the name for the country and region. Finally, I would alter the ordering of the results paragraphs, making sure the section on the whole genome sequencing analysis - starting on line 172 - is immediately after the isolate characterization section - ending on line 157. I have some minor spelling and grammatical revisions below too: Line 40 - "The National", should be replaced with Argentinian Line 40 - Suggest splitting this long sentence in two, inserting a full-stop for the "and" in this line, and then slightly expanding on the comprehensive characterization in sentence two. Line 44- References 1 & 2 should be inserted before the full-stop after "systemic diseases". Line 49 - Remove the abbreviation of non-typeable from the abstract and define the NT acronym after non-typeable in this line. Line 50 - The authors mention NT pneumococci are frequently encountered in colonization, then begin the next-sentence with "Although infrequent". Suggest they should make it clearer that NT strains are infrequent among cases of invasive pneumococcal disease. Perhaps start this sentence with "However, NT strains are seen infrequently in diseases …" Line 70 - Remove the "the" before immunosuppressive, it should read "the patient started immunosuppressive…" Line 72 - Need to define "HLA" here, what does the acronym stand-for? Line 77 - Should read "day 10", not "day 10th". Line 88 - Add a hyphen between Gram and positive: "Gram-positive" Line 94 - Rephrase "being followed as outpatient" to "being followed as an outpatient" Line 134 - Change "resist" to "fail". Line 149 and 151 - Italicize cpsA Line 189 - Remove the "On the other hand" at the beginning of this sentence. Line 213 - Introduce the pneumococcus name in the introduction of the article, not here in the discussion. Line 220 - Alter sentence slightly to "crucial for evading both immunological recognition and subsequent rapid clearance from the bloodstream" Lines 229:230 - Are there any references for the "Studies that suggest NT may be less susceptible to immune recognition"? Lines 247:249 - Move this sentence describing the detailed Kraken2 results into the results. Line 252 - Change "matching" to "match". Line 338 - Is reference 19 a website? If so please add in the url and the date accessed.
Please rate the quality of the presentation and structure of the manuscript
Good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
This case report focuses on an immunocompromised patient with atypical streptococcal pneumonia, SARS-CoV-2, and fungal infection. This is an interesting case, however, it is difficult to understand why they focused on non-typeable Streptococcus pneumonia in the presence of other concomitant infections. It is unclear what is novel in this report. In addition, as a case report, this report does not respect the elementary rules of scientific writing and should be substantially revised. I would like to point out the same problems with the title, abstract, and body of the report. I think that significant revisions are necessary for publication in a professional journal.
Please rate the quality of the presentation and structure of the manuscript
Very poor
To what extent are the …
Comments to Author
This case report focuses on an immunocompromised patient with atypical streptococcal pneumonia, SARS-CoV-2, and fungal infection. This is an interesting case, however, it is difficult to understand why they focused on non-typeable Streptococcus pneumonia in the presence of other concomitant infections. It is unclear what is novel in this report. In addition, as a case report, this report does not respect the elementary rules of scientific writing and should be substantially revised. I would like to point out the same problems with the title, abstract, and body of the report. I think that significant revisions are necessary for publication in a professional journal.
Please rate the quality of the presentation and structure of the manuscript
Very poor
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
-
Comments to Author
The authors could comment on the apparently inappropriate initial empirical treatment for oral mucosal irritation with cefazolin, gentamicin, acyclovir, nystatin and fluconazole.
Please rate the quality of the presentation and structure of the manuscript
Very good
To what extent are the conclusions supported by the data?
Strongly support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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