Title : Uncommon complications of invasive streptococcus pneumoniae post dental care
Abstract:
The gram-positive cocci S. pneumoniae, is the most common cause of pneumonia, with more than 500,000 cases reported each year in the United States (US). Rarely, S. pneumoniae may present as an invasive infection with a reported incidence of 8.6 cases per 100,000 people in the US. “Austrian Syndrome” first described by Osler in 1881, is a rare triad of pneumococcal endocarditis, meningitis, and pneumonia. Here, we present a case of invasive streptococcus pneumoniae infection with uncommon complications and resulting transient gammopathy.
A 54-year-old previously healthy male with past medical history of tobacco use disorder presented in late September with upper respiratory tract symptoms, acute mental status change and headache. He was admitted to the intensive care unit (ICU) for concerns of meningitis given his acutely altered state. Computed tomography (CT) scan of his brain did not show any acute etiology. Thus, he was initiated on empiric antibiotics to cover for bacterial meningitis and his mentation improved. Subsequently, he was stable for regular nursing floors. Blood cultures showed S. pneumoniae, antibiotics were continued. However, his hospital course was complicated by ongoing back pain and progressive confusion. Thus, he underwent a lumbar puncture which revealed S. pneumoniae as well. Despite appropriate antibiotics therapy, he developed worsening diffuse back pain and headache, with no neurological deficits. A magnetic resonance imaging (MRI) of the spine was completed showing cervical osteomyelitis/discitis and epidural abscess with canal stenosis. MRI of the brain was notable for left parietal lobe abscess. A transesophageal echocardiogram (TEE) was also obtained which showed mitral valve thickening, consistent with infective endocarditis in the setting of underlying rheumatic valve disease. Given the spine findings orthopedic surgery was consulted and the patient underwent C2-C6 posterior spinal fusion and C3-4 laminectomy for stabilization and no cultures were sent from the procedure. Given the aggressive nature of his infection, HIV testing, immunoglobulin levels, complement levels, and serum protein electrophoresis (SPEP) were completed. He was found to have gammopathy with multiple M spikes. Hematology was consulted.
Given the overall improvement in his clinical status, he was eventually discharged on high dose IV Ceftriaxone for an 8-week course with plans to follow-up with infectious disease and hematology/oncology. Subsequently, follow-up SPEP showed normal protein levels, with no unusual spike. The lack of a definitive respiratory process coupled with the infection's aggressive nature makes for an unusual presentation for streptococcus bacteremia. Given the overall clinical course, the most likely trigger for his infection may have been the underlying undiagnosed rheumatic mitral valve lesion, emphasizing the need for a broad work-up to identify possible source in the setting of S. pneumoniae bacteremia.
