Pneumococcal diseases remain one of the leading causes of vaccine-preventable death in children under 5 years of age. Conjugate vaccines have reduced invasive disease and colonization by vaccine serotypes, providing herd effect, but have also led to the emergence of new serotypes not covered by the vaccines. Brazilian surveillance data on bacterial meningitis identify serotype 19A as numerically and clinically relevant. Although it is one of the most prevalent serotypes in invasive pneumococcal disease, there are no data indicating higher lethality specifically due to serotype 19A. We present two fatal cases of pneumococcal meningitis in immunocompetent, vaccinated children without previous comorbidities, caused by serotype 19A. Case 1: Female child, 2 years and 8 months old, presented to the pediatric emergency department in June 2024 with productive cough, thick nasal discharge, fever and right ear pain for 2 days. Treatment with cefaclor was recommended and she was discharged. On the 4th day of antibiotic therapy, she was brought back due to prostration, vomiting and decreased urine output. Her general condition worsened after arrival, with tachycardia and marked adynamia; ceftriaxone was started and she was admitted to the ICU. Turbid CSF was collected, and Gram-positive diplococci were later identified on Gram stain; vancomycin was added empirically. CSF culture revealed S. pneumoniae resistant to ceftriaxone and susceptible to vancomycin, and blood cultures at admission identified the same agent. She progressed to convulsive episode on 07/02/2024; pupils became mid-dilated and non-reactive to light, with absent cough reflex and no response to pain. Brain death protocol was started on 07/03/2025, and death occurred on 07/05/2025. Case 2: Female child, 11 months old, presented to the pediatric emergency department in June 2025 after convulsive episode and decreased consciousness. About one week prior, she had fever and coryza, followed by vomiting and diarrhea on the day of admission. Ceftriaxone was initiated in the ED, with subsequent addition of vancomycin. CSF at admission showed Gram-positive diplococci, later confirmed as S. pneumoniae by culture. On the day after admission, pupils became mid-dilated and non-reactive, with absent cough reflex and no response to pain; she died in less than 4 days. In both cases, the Adolfo Lutz Institute identified serotype 19A in CSF samples.
Avilla et al. (Sun,) studied this question.