A 72–year–old male with a remote history of splenectomy secondary to Hodgkin’s lymphoma presented with high–grade fever and confusion for 3 days. Nine months prior to this admission, he was diagnosed with pneumococcal meningitis and pneumococcal mitral valve endocarditis. During that time, transesophageal echocardiogram (TEE) showed vegetation and abscess on posterior mitral leaflet for which he underwent mitral valve repair at the Hospital of the University of Pennsylvania. Five months later, he was again diagnosed with penicillin–sensitive pneumococcal mitral valve endocarditis; however, he responded promptly to medical therapy with ceftriaxone given over a 6–week period. He had received pneumococcal vaccination 2 years prior to this presentation. On examination during this admission, he was found to be febrile (104.3 F), confused and had a grade 2/6 systolic murmur at the apex. There were no meningeal signs, focal neurological deficits or stigmata of infective endocarditis. Laboratory data was significant for white blood cell count 22,400 cells/ul, bands 8% and serum creatinine 1.48 mg/dl. Chest X–ray and urine analysis were normal. Electrocardiogram revealed an old left bundle branch block. Blood cultures (4/4) revealed penicillin–sensitive streptococcus pneumoniae. TEE revealed small vegetation on the posterior mitral leaflet without any evidence of abscess and severe mitral regurgitation. Patient clinically responded to IV ceftriaxone. Due to recurrent pneumococcal mitral valve endocarditis and severe mitral regurgitation, patient is currently awaiting mitral valve replacement.
Although pneumococcal bacteremia is quite common, the incidence of pneumococcal endocarditis itself is extremely rare in immunosuppressed/ splenectomized patients. It can affect either native or prosthetic valve and has predilection for aortic valve. Very few cases of pneumococcal mitral valve endocarditis are reported. Tanawuttiwat et al. [J Heart Valve Dis, Sep 2011] reported a case of pneumococcal mitral valve endocarditis that had fulminant course with extremely rapid valve destruction. Given its acute presentation, peripheral stigmata of infective endocarditis are rarely seen. Gonzaga et al. [Microb Drug Resist, 1998] reported a case of emergence of penicillin resistance in recurrent pneumococcal endocarditis in an HIV patient. Our patient had penicillin–sensitive pneumococcal mitral valve endocarditis that recurred even after complete course of treatment with appropriate antibiotics and previous pneumococcal vaccination.
Pneumococcal vaccination may not be always protective and pneumococcal endocarditis should always be suspected in an immunosuppressed/splenectomized patient who presents with sepsis. The course of pneumococcal endocarditis in an immunosuppressed patient is usually aggressive and the surgeon may consider valve replacement surgery (over valve repair), if needed, during the initial episode.