A 48-year-old man, a heavy smoker and drinker, came to the emergency department complaining of pain, redness, and vision loss in his left eye (Figure A). Physical examination revealed a body temperature of 38.7°C and hyperemic left conjunctiva. His oral hygiene was clearly poor and he was missing a number of teeth. Auscultation disclosed the presence of a systolic murmur at the left sternal border, with no signs of heart failure or the peripheral stigmata of endocarditis. Transthoracic and transesophageal echocardiograms showed vegetations anchored on the mitral and tricuspid valves, with moderate mitral and tricuspid regurgitation (Figures B and C and videos 1 and 2 of the supplementary material).
The blood cultures were positive for Streptococcus pneumoniae and antibiotic therapy was initiated with benzyl penicillin. The patient completed his treatment, showing a favorable clinical course. In an echocardiogram performed prior to discharge, the vegetations had disappeared, but mitral and tricuspid regurgitation persisted. He did not recover the vision of his left eye.
Endophthalmitis is an unusual presentation of endocarditis, although this is the most common source of endogenous bacterial endophthalmitis. S pneumoniae is a highly unusual cause of endocarditis (only 1% to 3% of the cases). Alcoholic patients and smokers are especially susceptible to infection by S pneumoniae. It is important to recognize endophthalmitis as a possible initial sign of endocarditis in order to establish the correct diagnosis of this condition and proceed to early initiation of treatment.