Fulminant Septic Shock Due to Streptococcus pneumoniae Bacteremia Without Radiographic Pneumonia in an Immunocompetent Adult

Suwanee, GA

Introduction

Streptococcus pneumoniae is a leading cause of community-acquired pneumonia and invasive pneumococcal disease. Pneumococcal bacteremia is typically associated with radiographic evidence of pneumonia, with pulmonary consolidation present in the majority of cases. However, invasive disease may rarely present without radiographic findings, creating a diagnostic challenge. We report a case of fulminant septic shock due to S. pneumoniae bacteremia in an immunocompetent adult without radiographic pneumonia.

Methods

This is a retrospective case review of a 48-year-old previously healthy woman who presented to the emergency department with one day of cough, sore throat, and generalized weakness. Clinical data including laboratory values, imaging findings, microbiologic results, and hospital course were reviewed.

Results

On presentation, the patient was febrile (39.3°C), tachypneic, and profoundly hypotensive with mean arterial pressures in the 40s, requiring aggressive fluid resuscitation and vasopressor support. Laboratory evaluation demonstrated severe lactic acidosis, thrombocytopenia with a platelet nadir of 32 ×10⁹/L, acute kidney injury, coagulopathy, and markedly elevated procalcitonin. Blood cultures grew Streptococcus pneumoniae in two of two bottles, and urine pneumococcal antigen testing was positive. Chest radiography demonstrated no focal airspace consolidation, and computed tomography of the chest revealed no evidence of pneumonia, showing only small bilateral pleural effusions and dependent atelectasis. Empiric antimicrobial therapy with intravenous piperacillin–tazobactam and vancomycin was initiated on presentation and subsequently de-escalated to ceftriaxone following culture confirmation. The patient demonstrated rapid clinical improvement with normalization of lactate levels and recovery of organ function and was discharged home without residual deficits.

Discussion

This case highlights a clinically significant severity–imaging dissociation in invasive pneumococcal disease. Although pneumococcal bacteremia most commonly presents with radiographic pneumonia, hematogenous dissemination and systemic inflammatory activation may precede detectable pulmonary consolidation. In this patient, fulminant septic shock occurred despite minimal imaging findings. Clinicians should maintain high suspicion for invasive pneumococcal disease in patients presenting with septic shock, even in the absence of radiographic pneumonia. Early recognition and prompt antimicrobial therapy remain critical to survival.