A 61 year old woman presented with back pain and clinical signs of meningitis. Pleocytosis in the cerebrospinal fluid was found, but although Streptococcus pneumoniae was cultured from her blood it failed to grow from the cerebrospinal fluid. An echocardiogram detected vegetations on the mitral valve and a lesion at S1/S2 was demonstrated on a bone scan. Treatment for one month with benzylpenicillin (1200 mg four hourly) was successful for both the cardiac and neurological components of her infection, but her back pain only resolved after treatment was changed to clindamycin. The clinical presentation and metastatic spread of the S pneumoniae infection is much more commonly seen in the context of S aureus endocarditis. It is rare for the pneumococcus to be associated with endocarditis and when it is mortality is usually high. This case shows the metastatic potential of the organism and the requirement for appropriate antibiotics with regard not only to the sensitivity of the organism, but also for the site of infection.
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