Severe necrotising pneumonia in a fully immunised infant: A case of serotype 3 pneumococcal conjugate vaccine failure

Oligbu, G.; Ahmed, L.; Chia, G.
doi:10.1016/j.vacune.2018.09.002
 array:22 [
  "pii" => "S2445146018300207"
  "issn" => "24451460"
  "doi" => "10.1016/j.vacune.2018.09.002"
  "estado" => "S300"
  "fechaPublicacion" => "2018-07-01"
  "aid" => "114"
  "copyrightAnyo" => "2018"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Vacunas. 2018;19:99-102"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S2445146018300232"
    "issn" => "24451460"
    "doi" => "10.1016/j.vacune.2018.12.001"
    "estado" => "S300"
    "fechaPublicacion" => "2018-07-01"
    "aid" => "118"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Vacunas. 2018;19:103-4"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "es" => array:8 [
      "idiomaDefecto" => true
      "titulo" => "Preguntas y respuestas"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "103"
          "paginaFinal" => "104"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "L&#46; Urbiztondo, G&#46; Mirada, E&#46; Borr&#224;s"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Urbiztondo"
            ]
            1 => array:2 [
              "nombre" => "G&#46;"
              "apellidos" => "Mirada"
            ]
            2 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Borr&#224;s"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1576988718300578"
        "doi" => "10.1016/j.vacun.2018.11.001"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1576988718300578?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146018300232?idApp=UINPBA00004N"
    "url" => "/24451460/0000001900000002/v1_201901300630/S2445146018300232/v1_201901300630/es/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S2445146018300256"
    "issn" => "24451460"
    "doi" => "10.1016/j.vacune.2018.10.001"
    "estado" => "S300"
    "fechaPublicacion" => "2018-07-01"
    "aid" => "116"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Vacunas. 2018;19:85-98"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Scientific Societies Consensus</span>"
      "titulo" => "Executive summary of the update and reflection document on influenza vaccination in Spain"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "85"
          "paginaFinal" => "98"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Resumen ejecutivo del documento de actualizaci&#243;n y reflexi&#243;n sobre vacunaci&#243;n antigripal en Espa&#241;a"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "A&#46; Garc&#237;a, M&#46; Fern&#225;ndez-Prada, J&#46; Aristegui, D&#46; Moreno, E&#46; Redondo, I&#46; Jimeno, M&#46; Garc&#237;a Cenoz, J&#46;A&#46; Lopez Trigo"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Garc&#237;a"
            ]
            1 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Fern&#225;ndez-Prada"
            ]
            2 => array:2 [
              "nombre" => "J&#46;"
              "apellidos" => "Aristegui"
            ]
            3 => array:2 [
              "nombre" => "D&#46;"
              "apellidos" => "Moreno"
            ]
            4 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Redondo"
            ]
            5 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Jimeno"
            ]
            6 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Garc&#237;a Cenoz"
            ]
            7 => array:2 [
              "nombre" => "J&#46;A&#46;"
              "apellidos" => "Lopez Trigo"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S157698871830044X"
        "doi" => "10.1016/j.vacun.2018.10.001"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157698871830044X?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146018300256?idApp=UINPBA00004N"
    "url" => "/24451460/0000001900000002/v1_201901300630/S2445146018300256/v1_201901300630/en/main.assets"
  ]
  "en" => array:17 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Severe necrotising pneumonia in a fully immunised infant&#58; A case of serotype 3 pneumococcal conjugate vaccine failure"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "99"
        "paginaFinal" => "102"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "G&#46; Oligbu, L&#46; Ahmed, G&#46; Chia"
        "autores" => array:3 [
          0 => array:4 [
            "nombre" => "G&#46;"
            "apellidos" => "Oligbu"
            "email" => array:1 [
              0 => "godwin&#46;oligbu&#64;nhs&#46;net"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "L&#46;"
            "apellidos" => "Ahmed"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "G&#46;"
            "apellidos" => "Chia"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "London Northwest Healthcare Trust&#44; London&#44; UK"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Paediatric Infectious Diseases Research Group&#44; Institute for Infection and Immunity&#44; St&#46; George&#39;s&#44; University of London&#44; UK"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Neumon&#237;a necrotizante grave en un lactante completamente inmunizado&#58; un caso de fracaso de la vacuna conjugada neumoc&#243;cica serotipo 3"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1227
            "Ancho" => 755
            "Tamanyo" => 70636
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray &#40;A&#41; before treatment and &#40;B&#41; after treatment&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pneumoniae &#40;SP&#41;</span> is a major cause of bacterial pneumonia&#44; and is responsible for almost a million childhood deaths worldwide&#44; with 11&#37; of all deaths occurring in &#60;5 year-olds&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> In 2000&#44; the 7-valent vaccine &#40;PCV7&#41; that protects against the seven most prevalent pneumococcal serotypes &#40;4&#44; 6B&#44; 9V&#44; 14&#44; 18C&#44; 19F&#44; and 23F&#41; causing invasive pneumococcal disease &#40;IPD&#41; in children was licensed&#46; In 2010&#44; PCV7 was replaced with a 13-valent vaccine &#40;PCV13&#41; and&#47;or PCV 10 that aimed to protect against six additional serotypes &#40;1&#44;3&#44; 5&#44; 6A&#44; 7F&#44; and 19A&#41; and 3 additional serotypes 1&#44; 5&#44; and 7F respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> This conjugate vaccines are highly effective and led to a rapid decline in invasive pneumococcal disease &#40;IPD&#41; caused by vaccine-type across all age groups&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Nonetheless&#44; the development of vaccine-type IPD &#40;VT-IPD&#41; after completing the recommended course of PCV immunisation &#40;i&#46;e&#46; vaccine failure&#41; do occur&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> with serotype 3 &#40;ST3&#41; been one of the commonest serotype that has been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> A number of factors have been adduced to be responsible&#44; including the nasopharyngeal carriage and the capsular characteristics of this serotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; little is known about the characteristics of children who develop serotype-3 vaccine failure&#46; Here we describe a case of severe necrotising pneumonia in an age appropriately immunised infant&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case summary</span><p id="par0015" class="elsevierStylePara elsevierViewall">16 month-old fit and well presented unwell to the accident and emergency with a 2-day history of fever&#44; lethargy and increased work of breathing&#46; She has no significant past medical history and the only child of non-consanguineous parents&#46; She was born at term following an uneventful pregnancy and has been appropriately vaccinated for age</p><p id="par0020" class="elsevierStylePara elsevierViewall">On examination&#44; her weight and height were within the 50<span class="elsevierStyleSup">th</span> centile&#46; She was unwell&#44; with temperature&#44; 39&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; respiratory rate&#44; 52<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#59; heart rate 161<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#59; blood pressure&#44; 90&#47;50<span class="elsevierStyleHsp" style=""></span>mmHg and saturation&#44; 88&#37; on room air&#44; which improved to 96&#37; on 3<span class="elsevierStyleHsp" style=""></span>L of oxygen via nasal cannula&#46; She had a left-sided reduced air entry on auscultation&#46; Other systemic examinations were unremarkable&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Her peak CRP was 300<span class="elsevierStyleHsp" style=""></span>mg&#47;L &#40;normal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#41;&#44; and WBC 29&#47;L &#40;normal 5&#46;0&#8211;15&#46;0&#41;&#44; Neutrophil 19&#47;L &#40;normal 1&#46;5&#8211;8&#46;5&#41;&#44; Platelet 990&#47;L &#40;normal 150&#8211;410&#41;&#44; Albumin 24<span class="elsevierStyleHsp" style=""></span>g&#47;L &#40;normal 35&#8211;50&#41;&#46; Blood culture grew Streptococcus pneumoniae &#40;SP&#41;&#44; further immunological serotyping isolated serotype 3&#46; There was significant left sided shadowing on CXR&#46; Ultrasound showed loculated left pleural effusion and chest Computed Tomography was reported as large multilocular air cavity with mild mediastinal shift in keeping with necrosis secondary to infection &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>A&#41;&#46; Her detailed immunological work-up were normal&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">She was admitted initially with intravenous cefuroxime&#46; Vancomycin was added on D4 due to initial report of resistant to cephalosporin but extended testing in the reference laboratory showed susceptibility to penicillins&#44; cephalosporins&#44; carbapenems&#44; and levofloxacin&#46; Her clinical condition deteriorated on D9 with haematochezia and oedematous clinically&#46; Haemoglobin dropped to 53<span class="elsevierStyleHsp" style=""></span>g&#47;L&#44; blood film showed toxic granulation and deranged renal function test&#46; She was discussed with the renal team for possible haemolytic uraemic syndrome&#46; She required blood transfusion and vancomycin was switched to Linezolid&#46; She subsequently improved on Linezolid and was discharged on D20 for a further 2 weeks course of antibiotics and outpatient follow up&#46; Her follow up CXR showed significant improvement and recruitment in her lung tissue with normalisation of her of renal functions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">This case described a rare case of vaccine failure in a previously healthy child who has been appropriately immunised for age&#46; The development of vaccine-serotype IPD in a child who has been appropriately immunised with PCV &#40;ie&#44; vaccine failure&#41; is rare&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Our case is similar to that described by Conradi and colleague of a 15 month old infant who developed tension pneumothorax following serotype-3 necrotising pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> This child had a severe necrotising pneumonia&#44; requiring long-term hospitalisation and prolonged antibiotics&#46; Serotype 3 has been particularly implicated in lower respiratory tract infection&#44; complicated by empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> The characteristics of these children&#44; whether there are other associated underlying condition is usually unclear&#46; An underlying immune deficiency is more likely in children who develop IPD after 2 years of age&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> and those with recurrent IPD&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> This child had no associated co-morbidity and was fully evaluated for any possible immunodeficiency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">A recent study looking at vaccine response after an episode of IPD in the United Kingdom&#44; showed that&#44; although a significant proportion of vaccinated children with vaccine-type IPD did not achieve protective antibody thresholds against the infecting serotype even after vaccination post-IPD&#44; their IgG responses to the other vaccine serotypes remained intact&#44; indicating that an underlying antibody deficiency was unlikely&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In a cohort of 84 patient who had IPD in Catalonia after appropriate PCV13 vaccination&#44; 6 were reported to be due to serotype 3&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Similarly&#44; this child developed pneumococcal serotype 3-vaccine failure with no previous IPD or hospital admission&#46; Evidence have shown that individual pneumococcal serotypes have different propensities for invasiveness and disease&#44; and since vaccine immunogenicity varies for the different serotypes&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> It is therefore most likely that the IPD in this case is due to low vaccine effectiveness for this serotype that has been reported in England and Wales&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> In infants&#44; this serotype 3 elicited the lowest antibody response after primary and booster dose of PCV13 vaccine&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> It was therefore estimated that to confer some level of protection against serotype 3 IPD a very higher serum immunoglobulin G concentrations &#62;2&#46;83<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL are required compared to the internationally accepted threshold of 0&#46;35<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;mL<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>&#59; such high concentrations were rarely attained after vaccination&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> In addition to the low vaccine effectiveness&#44; serotype 3 strains have been reported to form mucoid colonies&#44; to be more heavily encapsulated with virulent potentials&#44; and has been associated with increase in nasopharyngeal carriage following PCV13 introduction&#44;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6&#44;7&#44;17</span></a> contributing to its prevalence&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion and clinical implication</span><p id="par0050" class="elsevierStylePara elsevierViewall">Although&#44; most IPD cases are currently not vaccine-preventable&#44; clinician should therefore be careful with well immunised children with PCV13 because they can develop severe IPD due to serotype not included and also included in the vaccine&#44; such as serotype 3&#46; An underlying immune deficiency is more likely in children with recurrent IPD&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> and the extent of immunological investigations should be at the discretion of the managing paediatrician&#46; Additional strategies will be required to reduce this devastating disease&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Authors&#8217; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">G&#46; O&#46;&#44; L&#46;A&#46;&#44; and G&#46;C&#46; reviewed the literature&#44; analysed the data&#44; wrote the first draft&#44; and coordinated the production of the manuscript&#46; G&#46;O&#46; had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis&#46; All authors were involved in the interpretation of the data and writing of the report&#59; all authors approved the final version</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Consent for publication</span><p id="par0060" class="elsevierStylePara elsevierViewall">Consent obtained from family for this publication&#44; including the images&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">No external funding was received for this piece of work&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:12 [
        0 => array:3 [
          "identificador" => "xres1142659"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1073302"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1142660"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1073303"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case summary"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion and clinical implication"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Authors&#8217; contributions"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Consent for publication"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Conflicts of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1073302"
          "palabras" => array:4 [
            0 => "Streptococcus pneumonia"
            1 => "Pneumococcal conjugate vaccine"
            2 => "Necrotising pneumonia"
            3 => "Vaccine failure"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1073303"
          "palabras" => array:4 [
            0 => "Neumon&#237;a estreptoc&#243;cica"
            1 => "Vacuna conjugada neumoc&#243;cica"
            2 => "Neumon&#237;a necrotizante"
            3 => "Falla de la vacuna"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of severe necrotising pneumonia in a fully immunised infant due to serotype 3 vaccine failure&#46; A full immunological work up was unremarkable&#44; and the child recovered fully with no residual complications&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos un caso de neumon&#237;a necrosante grave en una fallo de la vacuna contra el serotipo 3 de un lactante completamente inmunizado&#46; El trabajo inmunol&#243;gico completo fue normal y el ni&#241;o se recuper&#243; completamente sin complicaciones residuales&#46;</p></span>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1189
            "Ancho" => 755
            "Tamanyo" => 99978
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A &#38; B&#41; Crossectional CT showing large multilocular air cavity within the left lower lobe with mild mediastinal shift in keeping with necrosis secondary to infection&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1227
            "Ancho" => 755
            "Tamanyo" => 70636
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray &#40;A&#41; before treatment and &#40;B&#41; after treatment&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:17 [
            0 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years&#58; global estimates"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;L&#46; O&#8217;Brien"
                            1 => "L&#46;J&#46; Wolfson"
                            2 => "J&#46;P&#46; Watt"
                            3 => "E&#46; Henkle"
                            4 => "M&#46; Deloria-Knoll"
                            5 => "N&#46; McCall"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(09)61204-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2009"
                        "volumen" => "374"
                        "paginaInicial" => "893"
                        "paginaFinal" => "902"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19748398"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available at&#58; <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="http://webarchive.nationalarchives.gov.uk/20130107105354/http%3A/www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/Chiefmedicalofficerletters/DH_4137171">http&#58;&#47;&#47;webarchive&#46;nationalarchives&#46;gov&#46;uk&#47;20130107105354&#47;http&#58;&#47;www&#46;dh&#46;gov&#46;uk&#47;en&#47;Publicationsandstatistics&#47;Lettersandcirculars&#47;Professionalletters&#47;Chiefmedicalofficerletters&#47;DH&#95;4137171</a> &#91;accessed 12&#46;04&#46;18&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Planned changes to the routine childhood immunisation programme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Department of Health"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2006"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of the 13-valent pneumococcal conjugate vaccine on invasive pneumococcal disease in England and Wales 4 years after its introduction&#58; an observational cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "P&#46;A&#46; Waight"
                            1 => "N&#46;J&#46; Andrews"
                            2 => "S&#46;N&#46; Ladhani"
                            3 => "C&#46;L&#46; Sheppard"
                            4 => "M&#46;P&#46;E&#46; Slack"
                            5 => "E&#46; Miller"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(15)70044-7"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2015"
                        "volumen" => "15"
                        "paginaInicial" => "535"
                        "paginaFinal" => "543"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25801458"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pneumococcal conjugate vaccine failure in children&#58; a systematic review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Oligbu"
                            1 => "Y&#46; Hsia"
                            2 => "L&#46; Folgori"
                            3 => "S&#46; Collins"
                            4 => "S&#46; Ladhani"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.vaccine.2016.10.045"
                      "Revista" => array:4 [
                        "tituloSerie" => "Vaccine"
                        "fecha" => "2016"
                        "volumen" => "34"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27793484"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vaccine failures in patients properly vaccinated with 13-valent pneumococcal conjugate vaccine in Catalonia&#44; a region with low vaccination coverage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Moraga-Llop"
                            1 => "J&#46;J&#46; Garcia-Garcia"
                            2 => "A&#46; D&#237;az-Conradi"
                            3 => "P&#46; Ciruela"
                            4 => "J&#46; Martinez-Osorio"
                            5 => "S&#46; Gonzalez-Peris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000001041"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2016"
                        "volumen" => "35"
                        "paginaInicial" => "460"
                        "paginaFinal" => "463"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26658626"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of PCV13 on serotype 3 invasive pneumococcal disease and nasopharyngeal carriage in massachusetts&#8217; children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; Lapidot"
                            1 => "K&#46;M&#46; Shea"
                            2 => "B&#46;A&#46; Little"
                            3 => "I&#46; Yildrim"
                            4 => "S&#46;I&#46; Pelton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "InOpen Forum Infect Dis"
                        "fecha" => "2017"
                        "volumen" => "4"
                        "numero" => "suppl&#95;1"
                        "paginaInicial" => "S467"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Illustration of pneumococcal polysaccharide capsule during adherence and invasion of epithelial cells"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Hammerschmidt"
                            1 => "S&#46; Wolff"
                            2 => "A&#46; Hocke"
                            3 => "S&#46; Rosseau"
                            4 => "E&#46; Muller"
                            5 => "M&#46; Rohde"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1128/IAI.73.8.4653-4667.2005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Infect Immun"
                        "fecha" => "2005"
                        "volumen" => "73"
                        "paginaInicial" => "4653"
                        "paginaFinal" => "4667"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16040978"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characteristics and serotype distribution of childhood cases of invasive pneumococcal disease following pneumococcal conjugate vaccination in England and Wales&#44; 2006&#8211;2014"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Oligbu"
                            1 => "S&#46; Collins"
                            2 => "N&#46; Andrews"
                            3 => "C&#46;L&#46; Sheppard"
                            4 => "N&#46;K&#46; Fry"
                            5 => "M&#46;P&#46;E&#46; Slack"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/cix474"
                      "Revista" => array:4 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2017"
                        "volumen" => "65"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28531289"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tension pneumothorax following serotype-3 pneumococcal necrotizing pneumonia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "&#193;&#46;D&#46; Conradi"
                            1 => "R&#46;C&#46; Ferran"
                            2 => "A&#46;S&#46; Iranzo"
                            3 => "A&#46;C&#46; Torell"
                            4 => "J&#46;M&#46; Navarro"
                            5 => "C&#46; Munoz-Almagro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Pediatr Infect Dis"
                        "fecha" => "2014"
                        "volumen" => "9"
                        "paginaInicial" => "23"
                        "paginaFinal" => "25"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Parapneumonic pleural effusions caused by Streptococcus pneumoniae serotype 3 in children immunized with 13-valent conjugated pneumococcal vaccine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Antachopoulos"
                            1 => "M&#46;N&#46; Tsolia"
                            2 => "G&#46; Tzanakaki"
                            3 => "A&#46; Xirogianni"
                            4 => "O&#46; Dedousi"
                            5 => "G&#46; Markou"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000000041"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2014"
                        "volumen" => "33"
                        "paginaInicial" => "81"
                        "paginaFinal" => "83"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24172850"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Invasive pneumococcal disease in children can reveal a primary immunodeficiency"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Gaschignard"
                            1 => "C&#46; Levy"
                            2 => "M&#46; Chrabieh"
                            3 => "B&#46; Boisson"
                            4 => "C&#46; Bost-Bru"
                            5 => "S&#46; Dauger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/ciu274"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2014"
                        "volumen" => "59"
                        "paginaInicial" => "244"
                        "paginaFinal" => "251"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24759830"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Immunodeficiency among children with recurrent invasive pneumococcal disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Ingels"
                            1 => "L&#46; Schejbel"
                            2 => "A&#46;C&#46; Lundstedt"
                            3 => "L&#46; Jensen"
                            4 => "I&#46;A&#46; Laursen"
                            5 => "L&#46;P&#46; Ryder"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000000701"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2015"
                        "volumen" => "34"
                        "paginaInicial" => "644"
                        "paginaFinal" => "651"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25831419"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibody concentrations against the infecting serotype in vaccinated and unvaccinated children with invasive pneumococcal disease in the United Kingdom&#44; 2006&#8211;2013"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Brousseau"
                            1 => "N&#46; Andrews"
                            2 => "P&#46; Waight"
                            3 => "E&#46; Stanford"
                            4 => "E&#46; Newton"
                            5 => "R&#46; Almond"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/civ164"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2015"
                        "volumen" => "60"
                        "paginaInicial" => "1793"
                        "paginaFinal" => "1801"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25737376"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy&#44; safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Black"
                            1 => "H&#46; Shinefield"
                            2 => "B&#46; Fireman"
                            3 => "E&#46; Lewis"
                            4 => "P&#46; Ray"
                            5 => "J&#46;R&#46; Hansen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2000"
                        "volumen" => "19"
                        "paginaInicial" => "187"
                        "paginaFinal" => "195"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10749457"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serotype-specific effectiveness and correlates of protection for the 13-valent pneumococcal conjugate vaccine&#58; a postlicensure indirect cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46;J&#46; Andrews"
                            1 => "P&#46;A&#46; Waight"
                            2 => "P&#46; Burbidge"
                            3 => "E&#46; Pearce"
                            4 => "L&#46; Roalfe"
                            5 => "M&#46; Zancolli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1473-3099(14)70822-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Infect Dis"
                        "fecha" => "2014"
                        "volumen" => "14"
                        "paginaInicial" => "839"
                        "paginaFinal" => "846"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25042756"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Immunogenicity and reactogenicity of a 13-valent-pneumococcal conjugate vaccine administered at 2&#44; 4&#44; and 12 months of age&#58; a double-blind randomized active-controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;D&#46; Snape"
                            1 => "C&#46;L&#46; Klinger"
                            2 => "E&#46;D&#46; Daniels"
                            3 => "T&#46;M&#46; John"
                            4 => "H&#46; Layton"
                            5 => "L&#46; Rollinson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2010"
                        "volumen" => "29"
                        "paginaInicial" => "e80"
                        "paginaFinal" => "e90"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21155091"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Differences in serious clinical outcomes of infection caused by specific pneumococcal serotypes among adults"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;D&#46; Grabenstein"
                            1 => "L&#46;K&#46; Musey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.vaccine.2014.02.096"
                      "Revista" => array:6 [
                        "tituloSerie" => "Vaccine"
                        "fecha" => "2014"
                        "volumen" => "32"
                        "paginaInicial" => "2399"
                        "paginaFinal" => "2405"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24637174"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/24451460/0000001900000002/v1_201901300630/S2445146018300207/v1_201901300630/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "77038"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Clinical Note"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/24451460/0000001900000002/v1_201901300630/S2445146018300207/v1_201901300630/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445146018300207?idApp=UINPBA00004N"
]
Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter
