An uncommon manifestation of Streptococcus gallolyticus infective endocarditis with cerebral septic emboli

Abstract

Infective endocarditis (IE) can often present with neurological manifestations, due to embolization from valvular vegetation, but the presentation is often variable and unpredictable. Septic emboli to both occipital lobes supplied by the posterior cerebral arteries, resulting in visual disturbances are also an uncommon presentation of IE reported in the literature. While S. gallolyticus is a classical cause of IE, it is less common and usually occurs in a less suspecting group of patients with no predisposing cardiac conditions. We report the case of a 48-year-old man, who presented with predominant complaints of blurring of vision and temporal headache, without any other infective symptoms. The procalcitonin level was also normal even in the setting of bacteremia with septic embolism. The initial magnetic resonance imaging (MRI) showed multifocal enhancing lesions in cerebral hemispheres, cerebellum, and brainstem, with leptomeningeal enhancement. Transesophageal echocardiography and blood cultures subsequently confirmed diagnosis of S. gallolyticus IE of the mitral valve. The patient was treated with antibiotics upon diagnosis of IE. However, he developed intracranial hemorrhage secondary to mycotic aneurysms, and partial seizures. He eventually succumbed to the intracranial hemorrhage. This case serves to highlight that neurological manifestations can precede symptoms or signs of IE and the presentation are often variable. A high degree of clinical suspicion is needed to suspect neurological manifestations of IE, especially in patients without risk factors.