Pneumococcal endocarditis complicating meningitis and arthritis in a previously healthy woman: A case report

Abstract

Streptococcus pneumoniae is the most common cause of community-acquired bacterial meningitis in adults. Pneumococcal endocarditis coexisting with meningitis is rare, especially in healthy individuals. A 66-year-old woman was admitted with pneumococcal bacteremia, meningitis, and arthritis. She was in good condition before admission. Because of typical presentation of bacterial meningitis characteristics and normal echocardiographic findings, the patient was administered antibiotics for meningitis and arthritis. On hospitalization day 59, she developed a fever, and echocardiography showed severe aortic regurgitation, perforation, and vegetation of the aortic valve. She was diagnosed with pneumococcal endocarditis and underwent aortic valve replacement surgery. In general, invasive pneumococcal infections occur in debilitated middle-aged men with predisposing factors such as chronic alcoholism, chronic obstructive pulmonary disease, and immunosuppressive conditions. In this case, regardless of the appropriate treatment and no risk of invasive pneumococcal infections, infective endocarditis occurred. <Learning objective: This case suggested that invasive pneumococcal infections progressing to infective endocarditis can occur in healthy individuals and underscore the importance of careful observation in patients with pneumococcal meningitis, in particular, in the case of blood culture positive patients.>.

Keywords: Infective endocarditis; Invasive pneumococcal infections; Meningitis; Pneumococcal endocarditis; Streptococcus pneumonia.

Fig. 1

Transesophageal echocardiography. (a) Mid-esophageal long-axis view showing vegetation (arrow) of the noncoronary cusp. (b) Mid-esophageal long-axis color compares views showing perforation of the noncoronary cusp and severe aortic regurgitation.

Fig. 2

Clinical course after admission. The right knee joint fluid culture, two sets of blood cultures and CSF culture on admission grew penicillin-intermediate-sensitive Streptococcus pneumonia. All culture results were negative after antibiotic therapy. Transthoracic echocardiography (TTE) performed on day 2 showed no signs of valve disease and vegetation, but the results of TTE on day 59 showed perforation of severe aortic valve regurgitation and vegetation. CSF, cerebrospinal fluid; WBC, white blood cell; CRP, C-reactive protein; BT, body temperature; MRI, magnetic resonance image; TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; AVR, aortic valve replacement; VCM, vancomycin; MEPM, meropenem; CTRX, ceftriaxone; LVFX, levofloxacin.

Fig. 3

Pathological findings of the noncoronary cusp. (a and b) Low-power (original magnification 10×) microphotograph showing tissue destruction in the valve as observed after Elastica van Gieson staining. (c) High-power (original magnification 400×) microphotograph showing healed infective endocarditis, non-specific inflammatory cell infiltration, and no bacteria according to the results of hematoxylin and eosin staining.