Pneumococcal Endocarditis Presenting as Endophthalmitis

1Emory University, Atlanta, GA

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 110

Case Presentation:

A 64‐year‐old man with a medical history of hypertension and smoking presented to the emergency department (ED) with an acutely swollen and painful left eye, along with a 2‐week history of fevers, chills, and malaise. He was treated as an outpatient for iritis. After 2 additional weeks with similar symptoms and a cough, he was given PO tetracycline, as well as antibiotic eye drops. That evening, he woke up with dyspnea and chills, and 3 hours later, he had a syncopal episode. He was brought to the ED, where a physical exam revealed a fever, tachycardia, tachypnea, a wide pulse pressure, a III/VI diastolic murmur at the left sternal border, and bilateral rales. He had erythema, edema, and warmth around his left eye, and pus was noted in the anterior chamber. His neurological exam was non‐focal. Laboratory results included a leukocytosis with left‐shift and elevated cardiac enzymes. The chest x‐ray was consistent with pulmonary edema, and there were ST elevations on the ECG. He was intubated for respiratory distress in the ED, and a transthoracic echocardiogram revealed severe aortic insufficiency. The ophthalmologist diagnosed endophthalmitis, and a brain MRI later revealed numerous acute‐subacute infarctions. Broad‐spectrum systemic and intravitreal antibiotics were initiated and then narrowed when blood cultures grew penicillin‐sensitive Streptococcus pneumoniae. Hydralazine was given for after‐load reduction, and the patient's cardiac enzymes trended down without anticoagulation. After a catheterization was negative for significant coronary disease, he successfully underwent aortic valve replacement with a bioprosthetic valve. He has lost the vision in his left eye, and he remains cognitively impaired.

Discussion:

Streptococcus pneumoniae is an infrequent cause of infectious endocarditis. The upper or lower respiratory tract is usually the portal of entry. Mortality rate with pneumococcal endocarditis ranges from 28% to 60%, with those treated with surgery in addition to antibiotics having a better prognosis. Endogenous bacterial endophthalmitis is less common than endophthalmitis from exogenous sources such as trauma or intraocular surgery. It is usually associated with another infectious focus, such as a liver abscess, pneumonia, or endocarditis. Endophthalmitis is often misdiagnosed as uveitis or conjunctivitis, and it carries a poor prognosis for vision, especially when diagnosis is delayed.

Conclusions:

Because endocarditis can quickly progress to multiorgan disease via sepsis, embolic events, or valvular damage, hospital‐ists need to consider it even when signs and symptoms are ambiguous. Consultants should be involved early to optimize treatment, and surgery should be considered. Additionally, as this case demonstrates, eye infections require close follow‐up, and the differential diagnosis should be widened if there is not prompt response to therapy.

Author Disclosure:

D. P. Boyte, None.

To cite this abstract:

Boyte D. Pneumococcal Endocarditis Presenting as Endophthalmitis. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 110. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/pneumococcal-endocarditis-presenting-as-endophthalmitis/. Accessed July 17, 2019.

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