(573) Shot to the Heart, and to the Brain, S pneumoniae Gives Bacteremia a Bad Name

Introduction: Streptococcus pneumoniae is a pathogen responsible for various infections, including sinusitis, otitis media, pneumonia, meningitis, and bacteremia. Endocarditis due to S. pneumoniae is rare, representing less than 3% of endocarditis cases. Moreover, only 7.5% of pneumococcal meningitis cases are associated with endocarditis. We report a rare case of S. pneumoniae causing both endocarditis and meningitis.

Description: A 60-year-old male with a history of end-stage renal disease on hemodialysis and myelodysplastic syndrome presented with altered mental status. He complained of headache, jaw pain, neck stiffness, and subjective fevers to his family over the previous week. Notably, the patient had undergone a dental procedure a week prior. On examination, he was encephalopathic and unresponsive with lateral gaze deviation and generalized tonic rigidity, raising concerns for seizure. He was intubated for airway protection and started on antiepileptics.
Vital signs were significant for a fever of 39.4°C. He was empirically started on dexamethasone, vancomycin, ampicillin and ceftriaxone for suspected meningitis. A lumbar puncture revealed elevated opening pressures, hypoglycorrhachia, elevated protein levels, and neutrophilic predominance. Continuous electroencephalogram showed no seizure activity. A computed tomography of the head demonstrated evidence of mucosal thickening of the ethmoid air cells, sphenoid sinuses and maxillary sinuses as well as opacification of the right mastoid air cells, middle ear cavity, and left mastoid air cells. Blood cultures grew Streptococcus pneumoniae. A transthoracic echocardiogram revealed new aortic valve vegetations consistent with endocarditis. MRI confirmed meningitis and ventriculitis. Ultimately, the patient was successfully weaned off the ventilator and subsequently discharged home on antibiotics.

Discussion: This case describes a rare occurrence of pneumococcal endocarditis and meningitis likely stemming from a recent dental procedure leading to mastoiditis and sinusitis. The detection of vegetations on the aortic valve via echocardiography stresses the importance of cardiac imaging. This case emphasizes the need for thorough evaluation and prompt treatment, particularly in patients with multiple comorbidities and recent invasive procedures.