Patients, methods, and results

We studied all blood cultures that gave positive results from 1 July 1993 to 31 October 1994 in South Tees Health District (population 300000). Forty seven cultures grew isolates of S pneumoniae. Seven of the samples were from patients with a lymphoproliferative disorder (table).

In South Tees district about 200 patients have a lymphoproliferative disorder, giving an annual incidence of pneumococcal infection of 2.6% during the study. Four of the sevenpatients were hypogammaglobulinaemic and four were receiving corticosteroids. None of the patients was neutropenic and none had had a splenectomy. Mortality was 43% (table).

In this district about 180 patients have had a splenectomy (30000 nationwide). None developed pneumococcal septicaemia during the study period. Forty episodes of pneumococcal septicaemia thus occurred in the general population, giving an annual incidence of 0.01%. Of these 40 patients, only one was immunocompromised; this patient had ectodermal dysplasia and IgG2 deficiency but survived. Mortality was 25% (10 patients died).

Comment

This report highlights the increased risk of pneumococcal septicaemia in chronic lymphoproliferative malignancies (table). These patients tend to be elderly; only one was aged under 65. Mortality in these patients was higher (43%) than that in patients of all ages from South Tees who were not immunosuppressed by disease or drugs (25%).

Measures should be implemented to prevent such infections or at least initiate prompt referral and treatment. Similar measures have been proposed in those at high risk of sepsis after splenectomy and in those at risk of varicella infection while taking corticosteroids.1 3 The patient should be educated in the same way as patients who have had a splenectomy or who have a dysfunctional spleen.1 Patient information may be documented on a card, which the patient should carry at all times. General practitioners should be informed of the risks to these patients and the need for prompt referral to hospital.

Patients may be given a supply of penicillin (or amoxycillin) to be kept at home and taken when symptoms of sepsis develop. However, patients must also be advised to obtain urgent medical attention. Ciprofloxacin has variable activity against pneumoccus and therefore should not be used as first line treatment unless later sensitivities indicate otherwise.4 The drug was ineffective before admission in two of our patients (cases 1 and 6).

Lymphoproliferative malignancies are associated with hypogammaglobulinaemia. Prophylactic intravenous immunoglobulin is beneficial, especially in those who have low concentrations of functional IgG and are susceptible to recurrent bacterial infections.5

Immunisation with pneumococcal vaccine is associated with an impaired response in immunocompromised patients. If such patients are to be immunised those that do not show a rise in antibody titre could be considered for prophylactic intravenous immunoglobulin.