557 Streptococcus Pneumoniae: A Rare Case of Fulminant Multivalvular Infective Endocarditis Presenting With Septic Arthritis

Abstract

Streptococcus pneumoniae is an uncommon cause of native valve infective endocarditis in the post-antibiotic era. We present a rare case of disseminated s.pneumoniae infection presenting with septic arthritis, complicated by life-threatening Infective Endocarditis (IE). A 52 year old female presented to the emergency department (ED) with a painful swollen right knee two weeks after a fall. Fracture was excluded and a provisional diagnosis of ruptured Baker’s cyst was made. She re-presented by ambulance to ED two weeks later with fever, confusion and worsening knee swelling. Blood cultures and joint aspirate were positive for S. pneumoniae and joint washout was performed. On day 3 of admission, she deteriorated with hypotension, hypoxia and bilateral chest x-ray infiltrates requiring intubation and noradrenaline infusion. Bedside transthoracic echocardiogram on day 5 demonstrated a 1.5cm aortic valve vegetation with severe aortic regurgitation, aortic root abscess and mitral regurgitation. Transoesophageal echocardiogram confirmed severe endocarditis with aortic, mitral and tricuspid involvement, aortic root abscess and perforation of the interventricular septum and aorto-mitral curtain. She underwent emergency surgery with extensive debridement, ventricular septal defect closure, left ventricular outflow tract reconstruction, mitral and tricuspid valve repair, and mechanical aortic valve replacement. She required a pacemaker for postoperative atrioventricular block and has recovered completely. This report describes an unusual presentation of endocarditis caused by an uncommon and destructive pathogen, S. pneumoniae. It highlights the importance of early investigation for infective endocarditis in cases of bacteraemia with haemodynamic or respiratory compromise, even in pathogens uncommonly causing endocarditis.