www.elsevierhealth.com/journals/jinf

Journal of Infection (2007) 55, 106e110

REVIEW

Sinusitis complicated by dural sinus thrombosisand Streptococcus pneumoniae endocarditis:A case report and review of the literature

Julian Booker*, Daniel Musher

Cardiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA

Accepted 7 February 2007Available online 16 April 2007

KEYWORDSEndocarditis;Streptococcuspneumoniae;Pneumococcus;Dural sinus thrombosis;Cavernous sinusthrombosis

Summary Streptococcus pneumoniae endocarditis is most commonly associated with pneu-monia. It is relatively uncommon disease but its severity makes it clinically relevant.

We present a case and review of sinusitis complicated by both pneumococcal endocarditisand cavernous sinus thrombosis.

Both endocarditis and dural sinus thrombosis are known complications of facial infections.To our knowledge, this is the first reported case of both S. pneumoniae endocarditis and duralsinus thrombosis complicating sinusitis. A case report and review of the literature is presented.ª 2007 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction

Prior to the advent of widespread antibiotics, Streptococ-cus pneumoniae, or pneumococcus, was a relatively com-mon cause of bacterial endocarditis accounting forapproximately 15% of all cases.1 In contrast, at present,pneumococci account for <1e3% of cases of native valveendocarditis in adults.2e9 Most cases occur in associationwith pneumonia.2,10,11 We report a case of sphenoid sinus-itis leading to dural sinus thrombosis and ultimately pneu-mococcal endocarditis.

* Corresponding author. Tel.: þ1 713 433 1626.E-mail address: obooker@bcm.edu (J. Booker).

0163-4453/$30 ª 2007 The British Infection Society. Published by Elsedoi:10.1016/j.jinf.2007.02.011

Case presentation

A 37-year-old man was hospitalized because of a four-dayhistory of malaise, sinus discomfort, headache, and alteredmentation. On admission he had an early systolic murmurconsistent with mitral regurgitation, meningeal signs andleft sixth nerve palsy. Lumbar puncture was not donebecause the prothrombin time was markedly prolonged.The patient developed rapidly progressive unilateral prop-tosis, visual disturbance, and became more lethargic. Soonthereafter, CT imaging of the head revealed sphenoidinflammation consistent with sinusitis (Fig. 1) along withevidence for thrombosis of the cavernous sinus (Fig. 2)extending to the left sigmoid sinus and down to the left jug-ular bulb. There were also several hypodense areas sugges-tive of septic embolization present with associated mass

vier Ltd. All rights reserved.

Sinusitis complicated by dural sinus thrombosis and S. pneumoniae endocarditis 107

effect and diffuse edema. Further CT imaging yielded noevidence of cardiopulmonary disease including pneumonia,but there was evidence for embolism to the kidneys. Atransthoracic echocardiogram revealed a large, mobile

Figure 1 Inflammatory mucosal changes (arrow) consistentwith sphenoid sinusitis.

Figure 2 Ophthalmic vein dilation and thrombosis (arrow)which is highly suggestive of cavernous sinus thrombosis.

mitral valve vegetation (Fig. 3) with severe regurgitation.There was no discernable involvement of the aortic valve.Prior to the initiation of antibiotics, four blood cultures weredrawn, all of which grew penicillin-susceptible S. pneumo-niae. The patient was evaluated for possible repair of themitral valve, but surgery was not done because of complexnon-medical issues. The patient received meningitis dosedceftriaxone for a total of six weeks with significant improve-ment and was later discharged.

Methods

A Pubmed search of the English literature from 1966 to thepresent and reference lists from previously reviewedarticles yielded 306 cases of pneumococcal endocarditis.When available, the following information was collected:patient demographics, risk factors, additional sites ofinfection, complications of the illness, echocardiographicfindings, treatment modalities and mortality.

Results

Including the present case, 307 cases of pneumococcalendocarditis from the antibiotic era were reviewed. Asnoted previously by other authors, the most frequent riskfactor was chronic alcoholism, which was seen in 32% ofpatients. Male to female showed a male predominance witha ratio of 2.8:1. The lung continues to be the most frequentportal of entry accounting for at least half of all casesthough head and neck sources of infection are not un-common. The aortic valve is the most frequently involvedvalve followed by the mitral valve (Table 1).

Heart failure and embolic phenomena are commoncomplications being present 45% and 32%, respectively.The rate of mortality was lower in individuals who receiveda combined medical and surgical approach to treatmentcompared to antibiotics alone. The outcomes for patientswith penicillin-resistant strains of pneumococcus weresimilar to those with penicillin-susceptible strains (Table 2).

Figure 3 Large anterior leaflet mitral valve vegetation.

108 J. Booker, D. Musher

Discussion

Pneumococcal endocarditis, though not as prevalent as itonce was, is not an infrequent occurrence. Less than 1% ofindividuals with documented pneumococcal bacteremiawill develop endocarditis, which correlates to approxi-mately 1e3 cases per one million inhabitants per year.12

Table 1 Demographics and clinical characteristics

GenderMale 173Female 61Male:female 2.8:1

Risk factors (n Z 241)Mean age 51Alcoholism 76 32%Diabetes 13 5%Malignancy 17 7%HIV 17 7%Asplenia 7 3%

Valvular abnormalities (n Z 236)Native valvular disease 47 20%Prosthetic valve 12 5%

Portal of entry (n Z 181)Lung 92 51%ENT 27 15%Skin 2 1%GU 1 <1%GI 1 <1%Unknown 58 32%

Clinical manifestations (n Z 210)Pneumonia 104 50%Meningitis 109 52%Peripheral stigmata 10 5%Duration of symptoms (days) 12

Table 2 Cardiac findings and clinical outcomes

Complications (n Z 254)CHF 113 45%Arterial emboli 81 32%Brain 20 8%Other 63 25%

Valves involved (n Z 231)Aortic 141 61%Mitral 81 35%Tricuspid 25 11%Pulmonary 2 <1%2 or more 27 12%

MortalityAntibiotics alone 76/145 52%Combined surgery and antibiotics 27/95 28%PCN susceptible 19/99 19%PCN resistant 8/33 24%

The mortality, however, remains high with rates as highas 60%.6,10,11

A number of risk factors have been associated withinvasive pneumococcal disease including alcoholism, im-mune suppression, chronic disease, extremes of age, andpneumococcal serotype.1,12e16 Human Immune DeficiencyVirus (HIV) is a known risk factor for invasive S. pneumoniaethough its role as a risk factor for endocarditis is lesswell defined.17e19 Alcoholism and valvular heart diseaseare the most oft noted risk factors for developing thedisease.3,20e23

When pneumococcus infects endocardium, the aorticvalve seems to be particularly susceptible6,7,20 and is in-volved 61% of the time in our review (Table 2). Though sero-types 1, 8, and 12 have been reported as occurring mostfrequently,3 it is suggested that any serotype is capable ofendocardial infection.12 To date, no specific virulence factorfor increased risk of endocarditis has been identified.12,24

Pneumococcal endocarditis typically evolves secondaryto infection of the respiratory tract.6,7 Pneumonia remainsthe most commonly predisposing disease process and likelythe inciting event in most cases. Much less frequently, caseshave followed documented infections in the sinuses, otitismedia, septic abortion and tooth extraction.6,10,26 Endocar-ditis caused by S. pneumoniae is often associated withpneumonia and suppurative meningitis. This clinical syn-drome was initially described by Heschl in 1862 and thenagain by Osler in 1881 and is referred to as Austrian syn-drome or Osler’s triad.

This syndrome, when present in an individual withalcoholism, is sometimes called Osler’s tetrad.23

Pneumococcal endocarditis most frequently presentsacutely and with brisk clinical decompensation. Pneumo-coccal infection of cardiac valves is aggressive and leads torapid valvular destruction and circulatory collapse fromheart failure. There also is a tendency for the developmentof large friable vegetations, which are prone to emboliza-tion.27 Data from France suggest that early valve rep-lacement may lead to less early death17 probably due tocorrection of hemodynamically unstable valvular abnormal-ities and fewer embolic events.

Historically, penicillin has been the treatment of choicefor endocarditis due to pneumococcus. Although nearly 40%of S. pneumoniae in the United States show some level ofresistance to penicillin,28,29 plasma levels of penicillin arewell above the minimum inhibitory concentration for mostof the treatment period,30 and experimental data suggeststerilization of valvular vegetations due to pneumococcuswith high dose penicillin alone.31 Currently there is no evi-dence to support the concern that the use of penicillin totreat pneumococcal endocarditis caused by penicillin-resistant pneumococcus leads to poorer outcomes thoughmany clinicians would defer to another antibiotic choice.

Despite advances in therapy over the past decades, themortality from pneumococcal endocarditis remains high,though we found the mortality to be lower than previouslyreported by Aronin. The mortality rate of individuals whoundergo medical therapy alone continues to be higher thanthose treated with a combined medicalesurgical approach(Table 2), likely to the high rate of acute valvular insuffi-ciency with cardiovascular collapse, and the high rate ofembolic phenomena. A selection bias also likely exists, in

Sinusitis complicated by dural sinus thrombosis and S. pneumoniae endocarditis 109

which only the better candidates are taken for surgery. Thedecreased mortality found in this review compared to priorfindings is due to improved survival documented in recentyears.

It is unclear how much, if any protection is conferredwith previous vaccination against S. pneumoniae. There isvery limited data on the rate of endocardial infection in in-dividuals who have received the vaccine.21 Vaccination has,however, decreased the total number of invasive pneumo-coccal infections32e35 and presumably indirectly decreasesthe overall incidence of pneumococcal endocarditis.

Dural sinus thrombosis, as seen in our patient, is a well-known and feared complication of sinusitis that has alsobecome increasingly rare during the antibiotic era. Thecavernous sinus is affected most frequently.36 Infectionsoriginating in the middle third of the face are the mostlikely sources for septic thrombosis of the cavernous sinusas they drain to the ophthalmic vein and ultimately to thecavernous sinus.36e38 The mainstay of therapy for duralsinus thrombosis is antibiotics with varying indications forsurgery for the different regions of thrombosis.36,39e41

To our knowledge, this is the first reported case ofpneumococcal sinusitis complicated by both dural sinusthrombosis and endocarditis.

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