B51-14 Gemella Haemolysans as a Rare Cause of Multivalvular Endocarditis With Refractory Shock

Introduction Gemella haemolysans is a gram-positive coccus that normally inhabits the oral flora. It may appear gram-variable or coccobacillary, often complicating laboratory identification. Though rarely pathogenic, Gemella species can cause invasive infections such as meningitis and infective endocarditis. Fewer than 1% of all endocarditis cases are attributed to Gemella, and even fewer present with multivalvular involvement or critical illness. Case Presentation A 60-year-old Hispanic male with a history of nephrolithiasis, arthritis, and gastroesophageal reflux disease presented with six days of dyspnea, bilateral lower extremity petechial rash, and edema. On arrival, he was tachycardic, hypotensive, had a holosystolic murmur, and poor dentition. Imaging revealed pulmonary edema and splenomegaly. Transthoracic echocardiography showed an aortic valve vegetation with severe regurgitation and pulmonary hypertension. Transesophageal echocardiography confirmed a bicuspid aortic valve with left–right coronary cusp fusion, noncoronary cusp vegetation, and concurrent mitral valve vegetation with severe regurgitation and a small perforation.Blood cultures on admission revealed gram-positive cocci, though rapid multiplex polymerase chain reaction was unable to identify the species. The patient was started on empiric ceftriaxone and vancomycin. On hospital day three, Gemella haemolysans was identified, and therapy transitioned to penicillin G and gentamicin. Repeat cultures on day three were negative, but the patient remained hypotensive and dyspneic despite antibiotic therapy and diuresis, consistent with worsening valvular failure and pulmonary edema. He was transferred to a tertiary referral center for urgent cardiac surgery, though valve replacement was delayed five days pending family discussions. His respiratory distress worsened, requiring intubation and subsequent emergent aortic and mitral valve replacement. Postoperatively, he developed refractory shock requiring multiple vasopressors, including norepinephrine, vasopressin, angiotensin II, and methylene blue. Following goals-of-care discussions, the patient was transitioned to comfort measures and passed away. Discussion This case underscores the diagnostic and management challenges of Gemella haemolysans endocarditis, a rare but aggressive infection. While literature suggests favorable outcomes compared to Staphylococcus aureus or enterococcal endocarditis, this case demonstrates that Gemella can cause severe, multivalvular disease leading to critical illness and death in immunocompetent individuals. Conclusion Gemella haemolysans endocarditis should be recognized as a potentially life-threatening infection. Early organism identification, aggressive hemodynamic management, and timely surgical intervention are crucial. Delays in operative management, even for social or logistical reasons, may significantly worsen outcomes in hemodynamically unstable patients.