INTRODUCTION: Endocarditis caused by Lactobacilli species is rare and usually manifests in patients with severe comorbidities, congenital heart disease, or prosthetic valves. Lactobacilli species are gram-positive coccobacilli mostly found in the gastrointestinal tract flora. Current literature shows an association of this bacterium with the use of probiotics. We hypothesize a possible association between acute cholecystitis and the occurrence of Lactobacillus endocarditis in a patient with no history of use of probiotics. CASE DESCRIPTION/METHODS: A 75-year-old female with a history of Birt-Hogg-Dube Syndrome with multiple spontaneous pneumothoraxes, COPD, aortic stenosis status post prosthetic aortic valve (AV) replacement, presented with acute respiratory failure and septic shock. She was diagnosed with acute cholecystitis, severe aortic regurgitation, and found to have lactobacillus bacteremia. We started her on empiric antibiotic coverage and later switched to penicillin G and gentamicin following three positive blood cultures for Lactobacillus paracasei. A transesophageal echocardiogram showed vegetation with emerging severe aortic regurgitation, degeneration, and perforation of AV leaflet when compared with echocardiogram one year ago. A CT-thorax demonstrated pan lobular emphysema with large cysts and pneumatoceles at the lung bases. Bacteremia persisted for two weeks after initiation of antibiotic therapy. Treatment with penicillin G and gentamicin was deemed necessary for up to 4 weeks after definitive surgical treatment. However, the patient's severe lung condition complicated preoperative clearance, and she was transferred to a specialized center for open-heart AV replacement. DISCUSSION: Very few cases of Lactobacillus endocarditis are reported in the literature. A handful of studies describe some implicated pathogenesis of the Lactobacillus in the blood as induced by cholecystitis. Other studies suggest that the increased presence of Lactobacillus in the respiratory tract in cases of severe lung pathology can lead to hematogenous dissemination to the heart valves. However, the association between Lactobacillus species and prosthetic valve material (and implication with endocarditis) is currently well-established. All things considered, and despite the lack of histopathology, we suggest that the source of Lactobacillus was likely the acute cholecystitis, and the presence of lung comorbidities and prosthetic AV further exacerbated the patient's condition.

The COVID-19 pandemic has been a prime health issue since December 2019. Consequently, there has been an urgent need to prevent severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection and its associated morbidity and mortality. The currently available vaccines are designed to prevent infection. Their efficacy and safety have been demonstrated in clinical trials. Yet, given the short duration of the trials and the urgency to start vaccination, adverse events have been reported worldwide in real-life data format. Immune-mediated disease flares or new-onset inflammatory diseases following vaccine administration have recently been reported worldwide. Here, we present three cases of inflammatory arthritis (IA) caused by the BNT162b2 COVID vaccination, including two new-onset cases and one case of a flare of existing disease. The first case is new-onset IA, the second case is new-onset rheumatoid arthritis, and the third case is a flare of existing rheumatoid arthritis.Given the timeline of when our patients developed either a flare of their existing rheumatoid arthritis or new-onset IA or polymyalgia rheumatica (PMR) (a few days after receiving the COVID-19 vaccine), in addition to the currently available evidence of documented similar cases post administration of mRNA vaccines, as well as the link between their mechanism of action and the pathogenesis of those diseases, we can speculate a causal relationship between the vaccine and the triggering of these disease entities. In the future, it is important to consider that autoimmune diseases might be triggered or flared by the administration of vaccines, which appears to be associated with the COVID vaccine as well. Further evaluation of its incidence will provide additional clarity, though the rarity of this occurrence in the setting of more than half of the US population becoming vaccinated indicates that the benefit of the vaccine in terms of protection from COVID morbidity and mortality far outweighs this risk.

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