Abstract Introduction Streptococcus pneumoniae remains a significant cause of invasive bacterial infections despite widespread pneumococcal vaccination. While respiratory tract infections predominate, bacteremia can rarely lead to disseminated complications, including endogenous endophthalmitis (EE). The emergence of non-vaccine serotypes, such as 15A, excluded from PCV15 and PCV20 has contributed to breakthrough infections. We report an uncommon case of S. pneumoniae bacteremia complicated by EE in a vaccinated, immunocompetent adult. Case Description A 58-year-old Hispanic woman with hypertension, diabetes, and hyperlipidemia presented with one week of generalized weakness, fever (105 °F), myalgia, and lower extremity pain. Initial labs showed WBC 20,300/µL, sodium 123 mmol/L, CK 3,545 U/L, ESR 145 mm/hr, and CRP 27.2 mg/L. Blood and cerebrospinal fluid cultures grew S. pneumoniae. MRI spine and repeat lumbar puncture ruled out meningitis or myelitis; echocardiogram revealed no vegetations. The patient developed acute left-eye vision loss, and ophthalmologic examination showed dense vitritis and fibrin deposits, consistent with EE. Immunologic evaluation including complement levels, immunoglobulins, and peripheral smear for Howell-Jolly bodies was normal. CDC serotyping identified pneumococcal serotype 15A. The patient received ceftriaxone and vancomycin, later switched to moxifloxacin (CSF MIC = 1) for better ocular penetration. She was also treated with topical moxifloxacin, prednisolone acetate, brinzolamide/brimonidine, and atropine. Despite aggressive therapy, vision loss in the affected eye was irreversible, but systemic symptoms resolved and right-eye vision remained intact. Discussion This case illustrates an uncommon manifestation of pneumococcal bacteremia with endogenous endophthalmitis occurring in a vaccinated and immunocompetent host. It underscores the clinical impact of emerging non-vaccine serotypes such as 15A, associated with penicillin resistance and invasive disease. EE due to S. pneumoniae carries poor visual outcomes despite early recognition and broad-spectrum therapy. The inclusion of serotype 15A in the newly approved PCV21 (June 2024) may help mitigate such infections. Clinicians should maintain vigilance for invasive pneumococcal disease even in vaccinated individuals, particularly when ocular or neurological findings accompany sepsis. This abstract is funded by: none
Atalay et al. (Fri,) studied this question.