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Abstract

Introduction: Introduction End organ dysfunction related to infective endocarditis (IE) is a common cause for the referral to the intensive care unit. A thorough history and physical examination remains an integral part of management of patients with IE. Intensivists should maintain a high index of suspicion towards detecting rare manifestations of IE. We present a case of Methicillin sensitive Staphylococcus aureus (MSSA) endocarditis with two such rare complications in the form of bilateral endophthalmitis and parotitis which were diagnosed early and treated promptly. Case presentation A 63 year old male with a past history of mitral valve annuloplasty was hospitalized for fever with rigors of four day duration. His admission vitals were notable for fever (103 F), tachycardia and tachypnea. Physical examination revealed an apical holosystolic murmur and painful erythematous finger nodules (Osler's nodes).Pertinent positive labs included thrombocytopenia (count of 40,000), elevated BUN (60) and creatinine (1.7). Appropriate antibiotics were initiated for concern of IE; blood cultures grew Methicillin sensitive Staphylococcus aureus (MSSA) and subsequent work up with Trans-esophageal echocardiography showed mitral valve vegetation's (> 2 cm) on the anterior leaflet of the mitral valve with concomitant severe mitral regurgitation. Hospital course was complicated by the development of sudden painful bilateral parotid gland enlargement, bilateral decreased visual acuity and confusion. A thorough visual, neck and neurological exam revealed findings of bilateral endophthalmitis which was emergently treated with vitreous aspiration and intravitreal antibiotic instillation leading to an improvement in vision. Vitreal fluid cultures were positive for MSSA. Bilateral Parotid gland enlargement- acute parotitis secondary to disseminated sepsis was successfully treated with antibiotics and hydration. MRI of brain revealed multiple small cerebral infarcts and small areas of intracerebral hemorrhage consistent with septic infarcts and secondary hemorrhagic conversion. While the risks and benefits of emergent mitral valve replacement surgery were being contemplated, unfortunately only four days into the hospital course patient suffered a massive intracerebral hemorrhage and passed away. Discussion The pathogenesis for complications in IE includes embolic, local spread of infection, metastatic infection or immune-mediated damage. Embolization remains a distressingly common complication of IE and can occur even after appropriate therapy. Endogenous endophthalmitis is a rare complication of infective endocarditis that occurs due to direct invasion of ocular tissues (septic emboli) or by changes in vascular endothelium caused by substrates released during infection. The most common cause of the infection is Staphylococcus aureus. Endogenous endophthalmitis due to MSSA infective endocarditis is an extremely rare complication. Intravitreal and systemic antibiotic therapy should be initiated promptly. Acute bilateral parotitis is rare and is associated with mumps and connective tissue disorders; while in our case it seems to be secondary to MSSA bacteremia and septic emboli. Bilateral Endophthalmitis and Parotitis are very rare complications of infective endocarditis with only a few case reports published to date. Our patient is the first case in literature where both manifestations occurred together as a part of embolic phenomenon. Most common pathogen implicated in the setting of endocarditis is Staphylococcus aureus. Conclusion: Infective endocarditis (IE) is associated with a myriad of complications. It is important to recognize rare complications of IE like bilateral endophthalmitis and parotitis and act rapidly to prevent morbidity associated with it.