(646) A Case of Staphylococcus aureus Meningitis and Endocarditis From Hip Corticosteroid Injection

Introduction: Staphylococcus aureus can disseminate to many organs causing a spectrum of severe complications. We describe a case of S. Aureus septic arthritis with endocarditis, meningitis, and a hemorrhagic cerebral septic embolus.

Description: A healthy 52-year-old former athlete with left hip osteoarthritis presented to the emergency department with progressive encephalopathy and worsened left hip pain two weeks after a hip corticosteroid injection. On presentation he was febrile and tachypneic, but hemodynamically stable. His left hip had no external abnormality but demonstrated severe pain with passive range of motion. He was confused and lethargic, so a lumbar puncture was performed and yielded glucose 61 mg/dL, protein 77 mg/dL, WBC count 590 /uL (89% PMN), and cultures which grew S. Aureus. Blood cultures rapidly grew S. Aureus, and emergent washout of left hip purulence (grew S. Aureus) was performed on HD2. Throughout the admission he had an increasing systolic ejection murmur, explained by echocardiogram which revealed masses on the anterior and posterior mitral valve leaflets with two eccentric jets of regurgitation. MRI brain was significant for multiple septic emboli, with single left frontal lobe punctate hemorrhage. He had a mild but rising vasopressor requirement, with progressive hypoxia and pulmonary edema necessitating IV diuresis. Cardiac surgery was consulted for early valve replacement, with extensive discussions regarding anticoagulation safety given the cerebral hemorrhage. After unremarkable further preoperative workup (cerebral angiogram, MRI spine, coronary CT, and carotid doppler), he underwent open mitral valve replacement on HD8. The postoperative course was relatively uneventful, and the patient was discharged to rehab on HD21 then home on HD34. He completed a 6-week antibiotic course and is currently ambulatory but awaiting total hip arthroplasty.

Discussion: S. Aureus bacteremia is a high mortality condition that requires thorough identification and treatment of all active sources. We describe an excellent outcome attributed to prompt source control and early cardiac surgery despite significant risk.