10340 Clin Pathol 1992;45:1034-1035
Pneumococcal endocarditis and disseminated infection S R Heard, J Pickney, D S Tunstall-Pedoe
Department of Medical Microbiology, St Bartholomew's Hospital and Homerton Hospital S R Heard Department of General Medicine, Homerton Hospital
Pickney Department of General Medicine, St Bartholomew's Hospital and Homerton Hospital D S Tunstall-Pedoe
J
Correspondence to: Dr S R Heard, Department of Medical Microbiology, St Bartholomew's Hospital, West Smithfield, London EC 1
Accepted for publication 30 April 1992
Blood cultures, a full blood count, an ESR and Abstract A 61 year old woman presented with back a chest x-ray picture were taken and the patient pain and clinical signs of meningitis. Pleo- was given benzylpenicillin, 1-2 g two hourly. cytosis in the cerebrospinal fluid was The white cell count was 23 x 109/1 with 89% found, but although Streptococcus pneu- neutrophils, her ESR was 116 mm/first hour, moniae was cultured from her blood it and the lung fields were clear on chest x-ray failed to grow from the cerebrospinal picture. A sample of cerebrospinal fluid was fluid. An echocardiogram detected vege- obtained which showed 30 white blood cells x tations on the mitral valve and a lesion at 106/1 (90% neutrophils), 1280 red blood cells S1/S2 was demonstrated on a bone scan. x 10'/l, a protein concentration of 3 49 g/dl Treatment for one month with benzylpen- and a glucose concentration of less than 0 5 iciflin (1200 mg four hourly) was suc- mmol/l (blood glucose was 7-7 mmol/l). No cessful for both the cardiac and organisms were seen in the cerebrospinal fluid neurological components of her infection, and pneumococcal and meningococcal antigen but her back pain only resolved after latex tests (Wellcome) were negative (neat). There was insufficient cerebrospinal fluid to treatment was changed to clindamycin. The clinical presentation and metastatic titre to exclude a prozone effect. Lumbar spread of the S pneumoniae infection is puncture was repeated 24 hours later showing much more commonly seen in the context 350 white cells x 106/1 (80% neutrophils), 500 of S aureus endocarditis. It is rare for the red blood cells/mm3, a protein concentration of 1-86 g/dl and a glucose concentration of 0 1 pneumococcus to be associated with endocarditis and when it is mortality is usually mmol/l with a blood glucose of 7-7 mmol/l. high. This case shows the metastatic The pneumococcal latex test was, on this potential of the organism and the require- occasion, positive in the cerebrospinal fluid. ment for appropriate antibiotics with Three sets of blood cultures also grew a regard not only to the sensitivity of the mucoid Streptococcus pneumoniae (type 3), organism, but also for the site of infec- which was sensitive to benzylpenicillin, trimethoprim, and clindamycin. The organism tion. was not, however, subsequently grown from either sample of cerebrospinal fluid. In view of ( Clin Pathol 1992;45:1034-1035) the cardiac murmur, echocardiography was performed and showed a large vegetation on the mitral valve. A computed tomogram of the Case report A 61 year old Ghanaian woman attended the brain was normal. After the first 24 hours casualty department giving a four day history treatment was continued with benzylpenicillin of general malaise with pain in the right groin at 1200 mg four hourly for one month. Her and right buttock radiating down the right cardiac function remained stable, but with thigh. She had been resident in the United improvement of her neurological condition she Kingdom for eight years. She had no previous complained again of right sided low back pain. history of cardiac problems or of clinically Examination of the right hip was normal. A relevant illness. She neither smoked cigarettes plain x-ray picture showed some loss of definition of the margins of the L5-S 1 disc space, of nor drank alcohol. At presentation she had a temperature of 37 7'C and blood and protein uncertain relevance. After one month's treatin the urine on dipstick testing. She was sent ment with benzylpenicillin her ESR had fallen home with analgesics, but re-presented to her to 75 mm/hour. Forty eight hours after discontinuing antigeneral practitioner two days later. A urinary tract infection was diagnosed and trimetho- biotics she became feverish, with a temperature of 39'C and had a rigor. Repeat echocardiogprim was prescribed. Five days later she was admitted to hospital raphy showed the vegetation to be unchanged. complaining of recent onset of a frontal head- A Technetium-99 bone scan showed high ache and low back pain. On examination she uptake in the region of S 1 and S2, but had a pyrexia of 40'C, was drowsy with Technetium HMPOA white cell scanning pronounced neck stiffness and photophobia, showed reduced uptake in this area. Sampling and a positive Kernig's sign. She was confused of the L5-S1 disc space obtained by fluorand abusive. Her heart rate was 120/minute, oscopically controlled needle biopsy showed and her blood pressure was 120/70. She was no pus cells or organisms on Gram staining, noted to have a grade 2/6 mitral regurgitant and no growth was subsequently obtained. Her sustained ESR at 75 mm/h, her increasingly murmur. Bacterial meningitis was diagnosed.
Pneumococcal endocarditis and disseminated infection
1 035
severe back pain, and the bone scan results, in and noted its particular predilection for the the presence of her recent episode of endo- aortic valve. Until the introduction of penicillin carditis, strongly suggested a presumptive clin- the disease seems to have been uniformly fatal. ical diagnosis of pneumococcal osteomyelitis. Austrian reported eight cases in 1957, six of Oral clindamycin (300 mg three times a day) whom died.6 He noted that rupture of the replaced the benzylpenicillin. Her fever rapidly aortic valve was a common and often fatal settled and the ESR fell to 19 mm/hour over sequelae of the infection. The aortic valve has the next month. Her back pain completely been the site of most cardiac infections, but resolved within two months of receiving clinda- three of the St Thomas's patients did not have mycin. She received a total of 3 months' infection at this site and our patient had mitral treatment with clindamycin without any side valve endocarditis. Pneumococcal osteomyelitis is also only effects. At follow up, three months after treatment had stopped, her ESR was 13 mm/ rarely reported. Jacobs has recently reviewed hour and there was no evidence of vegetations 11 cases of paediatric pneumococcal osteoon her mitral valve. One year after her initial myelitis presenting over a 20 year period.7 presentation she was clinically well, with only Coleman reported 14 cases in his study in occasional backache, and a stable cardiac 19832 and none was reported from the St Thomas's study. Although in the present case murmur consistent with mitral regurgitation. the organism was not cultured from the aspirate of L5-S 1 obtained after four weeks of high dose benzylpenicillin, the patient's initial preDiscussion The largest prospective study of pneumococcal sentation involved back pain, and the bone bacteraemia was published by Gransden, scan was consistent with an inflammatory Eykyn, and Phillips from StThomas's Hospital process. Her ESR and back pain failed to in 1985.4 Seventy eight per cent of the 325 resolve after a long course of high dose patients studied presented with a bacteraemia (1200 mg two hourly) benzylpenicillin but and pneumonia alone, as the source of infec- both rapidly settled when clindamycin was tion. Three patients had pulmonary infection substituted. Clindamycin, an agent now infrein association with meningitis and endocarditis quently used in this country, especially in the and one patient also had empyema. All but two elderly because of earlier association with of the St Thomas's patients had an underlying pseudomembranous colitis,8 is a particularly predisposing condition in association with useful agent in this setting because of its good their sepsis and only one of the seven patients oral absorption and excellent penetration into with endocarditis was not alcoholic or cirr- bone. We have presented an unusual case of S hotic. Of the seven patients with endocarditis, six died and in five the diagnosis was only pneumoniae endocarditis which mimicked, in several salient features, the more familiar made at necropsy. This case thus has several distinctive fea- presentation of S aureus endocarditis. Mortaltures. There was no apparent predisposing ity from S pneumoniae septicaemia is high and factor to account for either the initial infection has increased over the past 14 years. As this or for its subsequent dissemination. Three case shows, it may present unusually with major focal sites-the heart, the brain, and the multi-organ involvement. Aggressive treatment bone-were involved in this infective process with appropriate antibiotics is required but but the lungs appeared normal with no evi- appropriate consideration to the site of infecdence of a pneumonia, either clinically or tion with the possibility of metastatic spread of radiologically. Moreover, the initial findings in the organism to sites such as heart or bone may the cerebrospinal fluid of this patient were not need to be considered. entirely typical. The oral trimethoprim given to the patient for a urinary tract infection probSurveillance of Streptococcus pneumoniae bacably suppressed the growth of the organism, 1 CDSC. teraemia and meningitis reports: 1975-1988. but the primary event may not have been Communicable Disease Report 1990;14:3-4. G, Hollas G. Systemic disease caused by pneumomeningitis but may have been related to the 2 Coleman cocci. J Infect 1983;7:248-55. endocarditis, with a clinical presentation of 3 Cheeseborough JS, Williams CL, Rustan R, Bucknall RC, Trimble RB. Metastatic pneumococcal endophthalmitis: meningism. Such a clinical picture is well report of 2 cases and review of literature. J Infect described for S aureus endocarditis which often 1990;20:231-6. WR, Eykyn SJ, Phillips I. Pneumococcal bacpresents in this way,5 but has not been recor- 4 Gransden teraemia: 325 episodes diagnosed at St. Thomas's Hospded with the pneumococcus. ital. Br Med J 1985;290:505-8. JN. Staphylococcus aureus: The persistent pathIndeed, endocarditis with this organism is 5 Sheagren ogen. N Engl 3 Med 1984;310:1368-73. rare but mortality is usually high. The associa- 6 Austrian R. Pneumococcal endocarditis meningitis and rupture of the aortic valve. Arch Intern Med 1957;99: tion of pneumonia, endocarditis, and meningi539-44. tis was first described in 1862 by Heschl after 7 Jacobs osteomyelitis and arthritis in NM. Pneumococcal J Dis Child 199 1; 145:70-4. children. necropsy of five patients. Netter then described 8 Tedesco FJ,AmBarton RW, Alpers DH. Clindamycin-assothis association with respect to pneumococcal ciated colitis: a prospective study. Ann Intern Med 1974;81 :429-33. endocarditis in 1886 in a review of 82 patients
Pneumococcal endocarditis and disseminated infection S R Heard, J Pickney, D S Tunstall-Pedoe
Department of Medical Microbiology, St Bartholomew's Hospital and Homerton Hospital S R Heard Department of General Medicine, Homerton Hospital
Pickney Department of General Medicine, St Bartholomew's Hospital and Homerton Hospital D S Tunstall-Pedoe
J
Correspondence to: Dr S R Heard, Department of Medical Microbiology, St Bartholomew's Hospital, West Smithfield, London EC 1
Accepted for publication 30 April 1992
Blood cultures, a full blood count, an ESR and Abstract A 61 year old woman presented with back a chest x-ray picture were taken and the patient pain and clinical signs of meningitis. Pleo- was given benzylpenicillin, 1-2 g two hourly. cytosis in the cerebrospinal fluid was The white cell count was 23 x 109/1 with 89% found, but although Streptococcus pneu- neutrophils, her ESR was 116 mm/first hour, moniae was cultured from her blood it and the lung fields were clear on chest x-ray failed to grow from the cerebrospinal picture. A sample of cerebrospinal fluid was fluid. An echocardiogram detected vege- obtained which showed 30 white blood cells x tations on the mitral valve and a lesion at 106/1 (90% neutrophils), 1280 red blood cells S1/S2 was demonstrated on a bone scan. x 10'/l, a protein concentration of 3 49 g/dl Treatment for one month with benzylpen- and a glucose concentration of less than 0 5 iciflin (1200 mg four hourly) was suc- mmol/l (blood glucose was 7-7 mmol/l). No cessful for both the cardiac and organisms were seen in the cerebrospinal fluid neurological components of her infection, and pneumococcal and meningococcal antigen but her back pain only resolved after latex tests (Wellcome) were negative (neat). There was insufficient cerebrospinal fluid to treatment was changed to clindamycin. The clinical presentation and metastatic titre to exclude a prozone effect. Lumbar spread of the S pneumoniae infection is puncture was repeated 24 hours later showing much more commonly seen in the context 350 white cells x 106/1 (80% neutrophils), 500 of S aureus endocarditis. It is rare for the red blood cells/mm3, a protein concentration of 1-86 g/dl and a glucose concentration of 0 1 pneumococcus to be associated with endocarditis and when it is mortality is usually mmol/l with a blood glucose of 7-7 mmol/l. high. This case shows the metastatic The pneumococcal latex test was, on this potential of the organism and the require- occasion, positive in the cerebrospinal fluid. ment for appropriate antibiotics with Three sets of blood cultures also grew a regard not only to the sensitivity of the mucoid Streptococcus pneumoniae (type 3), organism, but also for the site of infec- which was sensitive to benzylpenicillin, trimethoprim, and clindamycin. The organism tion. was not, however, subsequently grown from either sample of cerebrospinal fluid. In view of ( Clin Pathol 1992;45:1034-1035) the cardiac murmur, echocardiography was performed and showed a large vegetation on the mitral valve. A computed tomogram of the Case report A 61 year old Ghanaian woman attended the brain was normal. After the first 24 hours casualty department giving a four day history treatment was continued with benzylpenicillin of general malaise with pain in the right groin at 1200 mg four hourly for one month. Her and right buttock radiating down the right cardiac function remained stable, but with thigh. She had been resident in the United improvement of her neurological condition she Kingdom for eight years. She had no previous complained again of right sided low back pain. history of cardiac problems or of clinically Examination of the right hip was normal. A relevant illness. She neither smoked cigarettes plain x-ray picture showed some loss of definition of the margins of the L5-S 1 disc space, of nor drank alcohol. At presentation she had a temperature of 37 7'C and blood and protein uncertain relevance. After one month's treatin the urine on dipstick testing. She was sent ment with benzylpenicillin her ESR had fallen home with analgesics, but re-presented to her to 75 mm/hour. Forty eight hours after discontinuing antigeneral practitioner two days later. A urinary tract infection was diagnosed and trimetho- biotics she became feverish, with a temperature of 39'C and had a rigor. Repeat echocardiogprim was prescribed. Five days later she was admitted to hospital raphy showed the vegetation to be unchanged. complaining of recent onset of a frontal head- A Technetium-99 bone scan showed high ache and low back pain. On examination she uptake in the region of S 1 and S2, but had a pyrexia of 40'C, was drowsy with Technetium HMPOA white cell scanning pronounced neck stiffness and photophobia, showed reduced uptake in this area. Sampling and a positive Kernig's sign. She was confused of the L5-S1 disc space obtained by fluorand abusive. Her heart rate was 120/minute, oscopically controlled needle biopsy showed and her blood pressure was 120/70. She was no pus cells or organisms on Gram staining, noted to have a grade 2/6 mitral regurgitant and no growth was subsequently obtained. Her sustained ESR at 75 mm/h, her increasingly murmur. Bacterial meningitis was diagnosed.
Pneumococcal endocarditis and disseminated infection
1 035
severe back pain, and the bone scan results, in and noted its particular predilection for the the presence of her recent episode of endo- aortic valve. Until the introduction of penicillin carditis, strongly suggested a presumptive clin- the disease seems to have been uniformly fatal. ical diagnosis of pneumococcal osteomyelitis. Austrian reported eight cases in 1957, six of Oral clindamycin (300 mg three times a day) whom died.6 He noted that rupture of the replaced the benzylpenicillin. Her fever rapidly aortic valve was a common and often fatal settled and the ESR fell to 19 mm/hour over sequelae of the infection. The aortic valve has the next month. Her back pain completely been the site of most cardiac infections, but resolved within two months of receiving clinda- three of the St Thomas's patients did not have mycin. She received a total of 3 months' infection at this site and our patient had mitral treatment with clindamycin without any side valve endocarditis. Pneumococcal osteomyelitis is also only effects. At follow up, three months after treatment had stopped, her ESR was 13 mm/ rarely reported. Jacobs has recently reviewed hour and there was no evidence of vegetations 11 cases of paediatric pneumococcal osteoon her mitral valve. One year after her initial myelitis presenting over a 20 year period.7 presentation she was clinically well, with only Coleman reported 14 cases in his study in occasional backache, and a stable cardiac 19832 and none was reported from the St Thomas's study. Although in the present case murmur consistent with mitral regurgitation. the organism was not cultured from the aspirate of L5-S 1 obtained after four weeks of high dose benzylpenicillin, the patient's initial preDiscussion The largest prospective study of pneumococcal sentation involved back pain, and the bone bacteraemia was published by Gransden, scan was consistent with an inflammatory Eykyn, and Phillips from StThomas's Hospital process. Her ESR and back pain failed to in 1985.4 Seventy eight per cent of the 325 resolve after a long course of high dose patients studied presented with a bacteraemia (1200 mg two hourly) benzylpenicillin but and pneumonia alone, as the source of infec- both rapidly settled when clindamycin was tion. Three patients had pulmonary infection substituted. Clindamycin, an agent now infrein association with meningitis and endocarditis quently used in this country, especially in the and one patient also had empyema. All but two elderly because of earlier association with of the St Thomas's patients had an underlying pseudomembranous colitis,8 is a particularly predisposing condition in association with useful agent in this setting because of its good their sepsis and only one of the seven patients oral absorption and excellent penetration into with endocarditis was not alcoholic or cirr- bone. We have presented an unusual case of S hotic. Of the seven patients with endocarditis, six died and in five the diagnosis was only pneumoniae endocarditis which mimicked, in several salient features, the more familiar made at necropsy. This case thus has several distinctive fea- presentation of S aureus endocarditis. Mortaltures. There was no apparent predisposing ity from S pneumoniae septicaemia is high and factor to account for either the initial infection has increased over the past 14 years. As this or for its subsequent dissemination. Three case shows, it may present unusually with major focal sites-the heart, the brain, and the multi-organ involvement. Aggressive treatment bone-were involved in this infective process with appropriate antibiotics is required but but the lungs appeared normal with no evi- appropriate consideration to the site of infecdence of a pneumonia, either clinically or tion with the possibility of metastatic spread of radiologically. Moreover, the initial findings in the organism to sites such as heart or bone may the cerebrospinal fluid of this patient were not need to be considered. entirely typical. The oral trimethoprim given to the patient for a urinary tract infection probSurveillance of Streptococcus pneumoniae bacably suppressed the growth of the organism, 1 CDSC. teraemia and meningitis reports: 1975-1988. but the primary event may not have been Communicable Disease Report 1990;14:3-4. G, Hollas G. Systemic disease caused by pneumomeningitis but may have been related to the 2 Coleman cocci. J Infect 1983;7:248-55. endocarditis, with a clinical presentation of 3 Cheeseborough JS, Williams CL, Rustan R, Bucknall RC, Trimble RB. Metastatic pneumococcal endophthalmitis: meningism. Such a clinical picture is well report of 2 cases and review of literature. J Infect described for S aureus endocarditis which often 1990;20:231-6. WR, Eykyn SJ, Phillips I. Pneumococcal bacpresents in this way,5 but has not been recor- 4 Gransden teraemia: 325 episodes diagnosed at St. Thomas's Hospded with the pneumococcus. ital. Br Med J 1985;290:505-8. JN. Staphylococcus aureus: The persistent pathIndeed, endocarditis with this organism is 5 Sheagren ogen. N Engl 3 Med 1984;310:1368-73. rare but mortality is usually high. The associa- 6 Austrian R. Pneumococcal endocarditis meningitis and rupture of the aortic valve. Arch Intern Med 1957;99: tion of pneumonia, endocarditis, and meningi539-44. tis was first described in 1862 by Heschl after 7 Jacobs osteomyelitis and arthritis in NM. Pneumococcal J Dis Child 199 1; 145:70-4. children. necropsy of five patients. Netter then described 8 Tedesco FJ,AmBarton RW, Alpers DH. Clindamycin-assothis association with respect to pneumococcal ciated colitis: a prospective study. Ann Intern Med 1974;81 :429-33. endocarditis in 1886 in a review of 82 patients
