Endocarditis and pericarditis complicating pneumococcal bacteraemia, with special reference to the adhesive abilities of pneumococci: results from a prospective study

Streptococcus pneumoniae Serotype 23B Causing Asymptomatic Sinusitis Complicated by Endocarditis and Meningitis: Sequela of a Non-vaccine Serotype

We describe a rare case of a Streptococcus pneumoniae (S. pneumoniae) infection causing mitral valve endocarditis and bacterial meningitis in a previously healthy young adult male in his 20s who presented with altered mentation. Though our patient did not endorse any respiratory issues, we suspected the paranasal sinuses to have been the cryptic primary source of disseminated infection into the respiratory system and meninges due to incidental mucosal thickening being found on imaging. Blood and cerebrospinal fluid analyses and cultures revealed the proliferation of S. pneumoniae serotype 23B, despite our patient having previously received appropriate pneumococcal vaccinations in his childhood without delinquency. Ultimately, surgical replacement of the mitral valve, as well as a course of ceftriaxone, was indicated for this patient, in which full resolution of symptoms was achieved upon discharge.

Purulent Pericarditis Due to Pneumococcal Bacteremia Caused by Acupuncture: An Autopsy Case Report

Purulent pericarditis is an infection of the pericardial cavity that produces purulent fluid and is commonly caused by Streptococcus pneumoniae. We herein report an autopsy case that is unique in two respects: the patient had pneumococcal bacteremia from a skin and soft tissue infection associated with acupuncture as well as purulent pericarditis from pneumococcal bacteremia. This case suggests that bloodstream infection should be included in the differential diagnosis on observing pneumococcal pericarditis. Furthermore, it is necessary to recognize that S. pneumoniae may be the organism responsible for skin and soft tissue infections caused by trauma in immunosuppressed patients.

Pneumococcal pericarditis in a patient with newly diagnosed diabetes mellitus: a case report

Background

After the introduction of antibiotics, pneumococcal pericarditis has become a rare finding. However, this severe condition with high mortality and complication rates requires rapid recognition and intervention. Herein, we describe a patient that presents with this rare disease resulting in an unusual, fatal outcome.

Case presentation

A previously healthy, 68-year-old, Caucasian male presented with progressive fatigue, dyspnea, and appetite loss since 12 days. He was diagnosed with diabetes mellitus 5 days before presentation but had not started treatment. After echocardiography revealed pericardial effusion, pericardiocentesis was performed with immediate drainage of a large volume of purulent fluid suggestive of bacterial pericarditis. On the basis of cultures showing Streptococcus pneumoniae as the causative organism, a regimen of intravenous penicillin was initiated. Additionally, antidiabetic drugs were started as his diabetes also predisposed him to invasive infectious disease. No other primary source of the infection, such as pneumonia, was found. Though the patient was found to be severely ill on admission, his clinical condition improved. A total of 1235 mL of pericardial fluid was drained, and adequate drainage was confirmed by daily, bedside echocardiography. However, 6 days post-admission, the patient suddenly developed intrapericardial bleeding with blood clot formation on the right chamber with subsequent cardiac tamponade. With the blood clot precluding adequate drainage through the catheter, the patient suffered cardiac arrest and died before surgical intervention could be attempted.

Conclusions

Pneumococcal pericarditis is a very rare but life-threatening disease that necessitates immediate intervention with antibiotics and drainage of the pericardial effusion. Thus, although symptoms may be variable and aspecific, early recognition of this condition is critical. The present case illustrates the presentation, diagnosis, and clinical course of a patient presenting with pneumococcal pericarditis in current clinical practice. Through this report, we aimed to increase awareness among clinicians both of the existence of this phenomenon and of its uncertain clinical course. As is highlighted by the case, patients with pneumococcal pericarditis are at high risk for complications and should be closely monitored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13256-022-03548-8.

Platelets, Bacterial Adhesins and the Pneumococcus

Systemic infections with pathogenic or facultative pathogenic bacteria are associated with activation and aggregation of platelets leading to thrombocytopenia and activation of the clotting system. Bacterial proteins leading to platelet activation and aggregation have been identified, and while platelet receptors are recognized, induced signal transduction cascades are still often unknown. In addition to proteinaceous adhesins, pathogenic bacteria such as Staphylococcus aureus and Streptococcus pneumoniae also produce toxins such as pneumolysin and alpha-hemolysin. They bind to cellular receptors or form pores, which can result in disturbance of physiological functions of platelets. Here, we discuss the bacteria-platelet interplay in the context of adhesin–receptor interactions and platelet-activating bacterial proteins, with a main emphasis on S. aureus and S. pneumoniae. More importantly, we summarize recent findings of how S. aureus toxins and the pore-forming toxin pneumolysin of S. pneumoniae interfere with platelet function. Finally, the relevance of platelet dysfunction due to killing by toxins and potential treatment interventions protecting platelets against cell death are summarized.

Cardiovascular complications of Streptococcus pneumoniae bacteraemia

The incidence of Streptococcus pneumoniae bacteraemia has risen due to a worldwide increase in immunocompromised patients and antibiotic resistance. We describe three patients who experienced severe, including cardiovascular, complications of pneumococcal bacteraemia. Cardiovascular complications related to pneumococci may run a fulminant course. However, some of these life-threatening complications (eg, endocarditis and aortitis) may long remain unnoticed or be misdiagnosed and therefore delay correct treatment. We review the literature with regards to the incidence, diagnosis and treatment of these rare but possibly lethal and hence important cardiovascular complications.

Conquering the pneumococcal nemesis with oral antibiotics

Introduction: Streptococcus pneumoniae endocarditis (SPE) occurs in <3% of all EI cases due to the evolution of penicillin and vaccination. However, immunocompromised and unvaccinated patients are still at grave risk. Case: A 58-year-old African American male who used alcohol and intravenous (IV) drugs presented with confusion, fever, and hemoptysis. He had coarse rhonchi with a grade 2/5 holosystolic apical murmur. CT chest showed diffuse bilateral infiltrates. Blood cultures were positive for pansensitive Streptococcus pneumoniae. Echocardiogram demonstrated large vegetations on the anterior and posterior leaflets of the mitral valve with flail leaflet and severe eccentric mitral regurgitation. Patient was started on IV ceftriaxone, but after 3 weeks of therapy, he wished to leave against medical advice. He was discharged on combination oral therapy with successful resolution of SPE on follow-up. Discussion: Invasive pneumococcus is highly virulent causing irreversible valvular destruction or death. IV beta-lactams are first-line treatment, but there are currently no guideline-recommended alternatives for oral therapy. Recent data suggest partial oral therapy may be noninferior to IV only therapy. Conclusion: Switching to oral combination antibiotics after at least 2 weeks of IV therapy is an acceptable alternative to treat SPE.

Constrictive pericarditis following necrotising pneumococcal pneumonia in an immunocompetent child

Purulent pericarditis leading to constrictive pericarditis is a rare but serious complication following invasive pneumococcal infection. Early recognition of this complication is crucial to prevent mortality. Here, we report a previously healthy child who developed constrictive pericarditis due to purulent pericarditis following necrotising pneumococcal pneumonia, which is not common in this current antibiotic and pneumococcal vaccine era. The child was successfully treated with pericardiectomy.

ASSOCIATION OF MENINGITIS AND PERICARDITIS IN INVASIVE PNEUMOCOCCAL DISEASE: A RARE CASE

Objective:

To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis.

Case description:

This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol.

Comments:

Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.

Fulminant Pneumococcal Pericarditis in a Previously Healthy Patient

Purulent pericarditis is a rare acutely life-threatening condition. Initial symptoms, signs, and investigations can be nonspecific. Echocardiography is invaluable for establishing the diagnosis and initial management. We present a case of a previously healthy patient with purulent pericarditis caused by Streptococcus pneumoniae in the absence of a primary focus of infection. The patient deteriorated rapidly with cardiac tamponade and septic shock and was managed successfully by a combined medical and surgical approach.

Necrotizing pneumonia and acute purulent pericarditis caused by Streptococcus pneumoniae serotype 19A in a healthy 4-year-old girl after one catch-up dose of 13-valent pneumococcal conjugate vaccine

Streptococcus pneumoniae is a common cause of infectious diseases in children that may lead to life-threatening complications. Acute purulent pericarditis is an uncommon complication of S. pneumoniae in the antibiotic era. A healthy 4-year-old girl was admitted with pneumonia and pleural effusion. She had received one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age. She rapidly developed necrotizing pneumonia, complicated by bronchopleural fistula presenting as subcutaneous emphysema and pneumothorax and acute purulent pericarditis. S. pneumoniae serotype 19A was subsequently identified from blood, empyema and pericardial fluid cultures. After appropriate antibiotic therapy and a right lower lobectomy, her condition stabilized and she promptly recovered. This case highlights two rare potential clinical complications of pneumococcal disease in a child: necrotizing pneumonia and acute purulent pericarditis. This is the first report of a child who received just one catch-up dose of 13-valent pneumococcal conjugate vaccine at 2 years of age, as per the United States' Advisory Committee on Immunization Practice's recommendations, but who still developed severe invasive pneumococcal disease with life-threatening complications caused by S. pneumoniae serotype 19A.

Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series

Objective:

In the antibiotic era, purulent pericarditis is a rare entity. However, there are still reports of cases of the disease, which is associated with high mortality, and most such cases are attributed to delayed diagnosis. Approximately 40-50% of all cases of purulent pericarditis are caused by Gram-positive bacteria, Streptococcus pneumoniae in particular.

Methods:

We report four cases of pneumococcal pneumonia complicated by pericarditis, with different clinical features and levels of severity.

Results:

In three of the four cases, the main complication was cardiac tamponade. Microbiological screening (urinary antigen testing and pleural fluid culture) confirmed the diagnosis of severe pneumococcal pneumonia complicated by purulent pericarditis.

Conclusions:

In cases of pneumococcal pneumonia complicated by pericarditis, early diagnosis is of paramount importance to avoid severe hemodynamic compromise. The complications of acute pericarditis appear early in the clinical course of the infection. The most serious complications are cardiac tamponade and its consequences. Antibiotic therapy combined with pericardiocentesis drastically reduces the mortality associated with purulent pericarditis.

Characteristics and Outcome of Streptococcus pneumoniae Endocarditis in the XXI Century: A Systematic Review of 111 Cases (2000-2013)

Streptococcus pneumoniae is an infrequent cause of severe infectious endocarditis (IE). The aim of our study was to describe the epidemiology, clinical and microbiological characteristics, and outcome of a series of cases of S. pneumoniae IE diagnosed in Spain and in a series of cases published since 2000 in the medical literature. We prospectively collected all cases of IE diagnosed in a multicenter cohort of patients from 27 Spanish hospitals (n = 2539). We also performed a systematic review of the literature since 2000 and retrieved all cases with complete clinical data using a pre-established protocol. Predictors of mortality were identified using a logistic regression model. We collected 111 cases of pneumococcal IE: 24 patients from the Spanish cohort and 87 cases from the literature review. Median age was 51 years, and 23 patients (20.7%) were under 15 years. Men accounted for 64% of patients, and infection was community-acquired in 96.4% of cases. The most important underlying conditions were liver disease (27.9%) and immunosuppression (10.8%). A predisposing heart condition was present in only 18 patients (16.2%). Pneumococcal IE affected a native valve in 93.7% of patients. Left-sided endocarditis predominated (aortic valve 53.2% and mitral valve 40.5%). The microbiological diagnosis was obtained from blood cultures in 84.7% of cases. In the Spanish cohort, nonsusceptibility to penicillin was detected in 4.2%. The most common clinical manifestations included fever (71.2%), a new heart murmur (55%), pneumonia (45.9%), meningitis (40.5%), and Austrian syndrome (26.1%). Cardiac surgery was performed in 47.7% of patients. The in-hospital mortality rate was 20.7%. The multivariate analysis revealed the independent risk factors for mortality to be meningitis (OR, 4.3; 95% CI, 1.4-12.9; P < 0.01). Valve surgery was protective (OR, 0.1; 95% CI, 0.04-0.4; P < 0.01). Streptococcus pneumoniae IE is a community-acquired disease that mainly affects native aortic valves. Half of the cases in the present study had concomitant pneumonia, and a considerable number developed meningitis. Mortality was high, mainly in patients with central nervous system (CNS) involvement. Surgery was protective.

Pneumococcal endocarditis complicating meningitis and arthritis in a previously healthy woman: A case report

Streptococcus pneumoniae is the most common cause of community-acquired bacterial meningitis in adults. Pneumococcal endocarditis coexisting with meningitis is rare, especially in healthy individuals. A 66-year-old woman was admitted with pneumococcal bacteremia, meningitis, and arthritis. She was in good condition before admission. Because of typical presentation of bacterial meningitis characteristics and normal echocardiographic findings, the patient was administered antibiotics for meningitis and arthritis. On hospitalization day 59, she developed a fever, and echocardiography showed severe aortic regurgitation, perforation, and vegetation of the aortic valve. She was diagnosed with pneumococcal endocarditis and underwent aortic valve replacement surgery. In general, invasive pneumococcal infections occur in debilitated middle-aged men with predisposing factors such as chronic alcoholism, chronic obstructive pulmonary disease, and immunosuppressive conditions. In this case, regardless of the appropriate treatment and no risk of invasive pneumococcal infections, infective endocarditis occurred. <Learning objective: This case suggested that invasive pneumococcal infections progressing to infective endocarditis can occur in healthy individuals and underscore the importance of careful observation in patients with pneumococcal meningitis, in particular, in the case of blood culture positive patients.>.

Evaluation of postmortem bacterial migration using culturing and real-time quantitative PCR

Postmortem bacteriology can be a valuable tool for evaluating deaths due to bacterial infection or for researching the involvement of bacteria in various diseases. In this study, time-dependent postmortem bacterial migration into liver, mesenteric lymph node, pericardial fluid, portal, and peripheral vein was analyzed in 33 autopsy cases by bacterial culturing and real-time quantitative polymerase chain reaction (RT-qPCR). None suffered or died from bacterial infection. According to culturing, pericardial fluid and liver were the most sterile samples up to 5 days postmortem. In these samples, multigrowth and staphylococci were not or rarely detected. RT-qPCR was more sensitive and showed higher bacterial positivity in all samples. Relative amounts of intestinal bacterial DNA (bifidobacteria, bacteroides, enterobacter, clostridia) increased with time. Sterility of blood samples was low during the studied time periods (1-7 days). The best postmortem microbiological sampling sites were pericardial fluid and liver up to 5 days after death.

Pneumococcal pneumonia complicating purulent pericarditis in a previously healthy girl: a rare yet possible fatal complication in the antibiotic era

Purulent pericarditis is an extremely rare complication of invasive Streptococcus pneumoniae infection among children in the antibiotic era, and its mortality remains high if left untreated. This report involves a 4½-year-old girl who presented to our emergency department with productive cough, shortness of breath, and left-sided chest pain with a diagnosis of pneumococcal pneumonia. She subsequently developed life-threatening conditions including bilateral empyema with respiratory failure, purulent pericarditis, and multiple organ failure leading to death. The case highlights that purulent pericarditis is a rare yet possible disorder complicating pneumococcal disease in the antibiotic era. The increase in strains resistant to penicillin should alert emergency physicians to the potential for reemergence of pneumococcal pericarditis in children.

Diagnosis of pneumococcal pericarditis using antigen testing and polymerase chain reaction

Following the advent of antibiotics, pneumococcal pericarditis has become a rare clinical diagnosis. We discuss 2 cases of pneumococcal pericarditis that were preceded by community-acquired pneumonia. Cultures were negative in both patients and the diagnosis was made by antigen testing and polymerase chain reaction (PCR) of the pericardial fluid. PCR or antigen testing of pericardial fluid for pneumococci should be considered in patients with a typical history, particularly when culture-negative and with a history of prior antibiotics.

Severe bivalvular pneumococcal endocarditis and suppurative pericarditis in an immunocompetent patient

Pneumococcal endocarditis is a very serious and rare clinical entity that results in significant morbidity and high mortality rates. It causes severe disease and is typically seen in alcoholics and immunocompromised patients. Antimicrobial therapy and timely surgery are warranted for optimal management and improving outcomes. We present a case of a previously healthy 31-year-old Hispanic man with bicuspid aortic valve who developed severe bivalvular pneumococcal endocarditis complicated by suppurative pericarditis that was promptly treated with antimicrobial therapy and subsequent aortic valve replacement with initial favorable clinical and hemodynamic improvement.

An unusual complication of pneumococcal pneumonia: Acute tamponade due to purulent pericarditis

The incidence of purulent pericarditis has declined, however mortality remains high. Few cases so far of cardiac tamponade related with purulent pericarditis which is a rare complication of pneumococcal pneumonia have been published in the literature. We report a case of the development of cardiac tamponade due to pneumococcal pneumonia and emphasize the importance of early recognition, prompt institution of appropriate antibiotic therapy, and early surgical drainage for survival.

Rare case of Nocardia asteroides pericarditis in a human immunodeficiency virus-infected patient

Nocardia asteroides was isolated after prolonged culture from the pericardial fluid of a human immunodeficiency virus-infected patient. The lengthy duration required for culture growth and identification of this N. asteroides isolate affected both initial therapeutic decisions and patient management. A proposed algorithm for the microbiological workup of pericardial fluid for possible Nocardia spp. is described in an effort to improve the timeliness of results.

Sinusitis complicated by dural sinus thrombosis and Streptococcus pneumoniae endocarditis: a case report and review of the literature

Streptococcus pneumoniae endocarditis is most commonly associated with pneumonia. It is relatively uncommon disease but its severity makes it clinically relevant. We present a case and review of sinusitis complicated by both pneumococcal endocarditis and cavernous sinus thrombosis. Both endocarditis and dural sinus thrombosis are known complications of facial infections. To our knowledge, this is the first reported case of both S. pneumoniae endocarditis and dural sinus thrombosis complicating sinusitis. A case report and review of the literature is presented.