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Program

Internal Medicine

Training Level

Resident PGY 1

Institution

Henry Ford Hospital

Abstract

Introduction: Invasive streptococcus pneumoniae (ISP) is an isolated infection of Streptococcus pneumoniae in normally sterile sites (e.g. blood, CSF, synovial fluid). It is typically seen in adults >65 years of age or children <2 years of age and immunocompromised individuals. Mortality rates range between 15-20% and are highest during the first 72 hours after bacteremia is identified. S. pneumoniae is an uncommon cause of infective endocarditis (IE). The extent of damage to the cardiac valves is a key prognostic factor, thus it is essential for early detection and timely medical and/or surgical intervention. Our case involves a 50-year-old immunocompetent male who presented with ISP with IE secondary to a tooth abscess.Case Presentation: A 50-year-old African American male with no past medical historynor substance abuse history who presented with decreased right visual acuity with associated photophobia, pain and swelling of his right wrist, andright lower extremity weakness. Exam was significant for poor dentition. He had right-sided peri-orbital erythema with elevated intra-ocular pressure, as well as edema and erythema of his left sternoclavicular joint and right wrist. Strength was 4/5 in theright lower extremity with intact sensation. A 3/5 holosystolic murmur was present at the apex.Initial labs were significant for leukocytosis, elevated ESR and CRP, and transaminitis. Chest x-ray was unremarkable. CT Liver significant for hepatic hemangiomas and L4 rim-enhancing fluid collection confirmed to be a paraspinal abscess on MRI.MRI of the thoracic spine revealed a left sternomanubrial fluid collection and mediastinitis. Orthopantogram revealed bilateral mandibular molar abscesses. TTE/TEE both revealed a 16.5 x 7.9 mm vegetation and abscess on the anterior mitral leaflet. Cultures of blood, right eye aspiration, joint aspirations, and paraspinal fluid collection were all positive for S. pneumoniae. He underwent a right vitrectomy for endophthalmitis, debridement of the manubrium for osteomyelitis, and eventually mitral valve debridement of the perforation in the anterior leaflet and annuloplasty. During his hospitalization, he was evaluated for an immunosuppressive condition, however workup including HIV, ANA, C3/C4, SPEP/UPEP, immunoglobulin levels, Sickle Cell, and peripheral blood smear were all unremarkable. He completed a 6-week course of IV Ceftriaxone and made a full recovery.Discussion: ISP is an isolated infection of Streptococcus pneumoniae in normally sterile sites (e.g. blood, CSF, synovial fluid). It is typically seen in adults>65 years of age or children <2 years of age, and immunocompromised individuals. Mortality rates range between 15-20% and is highest during the first 72 hours after bacteremia is identified.S. pneumoniae causes approximately 6% of cases of IE, but the extent of damage to the cardiac valves is a key prognostic factor, thus it is essential for early detection and timely medical and/or surgical intervention.CConclusion: It is important to assess for endocarditis in patients with S. penumoniae bacteremia and to evaluate for potential causes of immunosuppression, however, ISP can occur in immunocompetent individuals. It is also urgent to initiate antibiotic management within 72 hours of positive blood cultures and prompt surgical evaluation to decrease mortality.

Presentation Date

5-2019

Invasive streptococcus pneumoniae in an immunocompetent host

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