Endophthalmitis, pneumonia, and a heart murmur
A 50 year old woman was admitted to the emergency room because of loss of vision in her right eye. She was a healthy woman until three weeks earlier when she developed fever and cough. A seven day course of amoxicillin was prescribed, but she continued with the symptoms. The day before admission, she developed a red eye.
On physical examination, her temperature was 38°C. The conjunctiva of her right eye was injected. She presented peripheral stigmata as petechiae, splinter haemorrhages, and Janeway lesions. A systolic murmur was heard along the left sternal border and apex. Crackles were present in the left lung. There was notable peripheral oedema.
She had anaemia and thrombopenia, and a long prothrombin time. Chest x rays showed a consolidation in the upper left lobe. A transthoracic echocardiogram was performed showing a vegetation attached to the posterior leaflet of the mitral valve and severe mitral regurgitation. The ophthalmologic evaluation disclosed bilateral endophthalmitis.
Blood cultures were negative, but diplococcus was found in the vitreous sample, and the urine was positive for Streptococcus pneumoniae. After diagnosing pneumococcal pneumonia with endocarditis and endophthalmitis, antibiotic treatment was started; however the patient’s condition deteriorated so mitral valve replacement was undertaken. The patient died 10 days later from septic shock.
S pneumoniae is a rare cause of endocarditis, accounting for only 1–3% of cases. Its prognosis is worse than S viridans endocarditis. Endocarditis is the most common source of endogenous bacterial endophthalmitis, and streptococcus is the most commom organism.