MRSA hypopyon. From PMID: 20234775.

Thanks Betty Lai for a fascinating case of Group B strep infective endocarditis presenting as hypopyon. Great job to all the participants in getting the diagnosis purely from the history!

Learning points:
– When evaluating multi-organ system damage, consider metastatic infective endocarditis in your differential.
– Obtain blood cultures prior to antibiotics. If patient is stable and infection is subacute, goal of 3 blood culture for maximal sensitivity.
– Initial treatment is highly dependent on patient’s predisposition for bacterial species (e.g., native valve vs. prosthetic valve, dental work vs. IVDU). Consider ceftriaxone and vancomycin as initial treatment in acute bacterial endocarditis of native valve.
– New PR interval prolongation in the setting of bacteremia is suggestive of perivalvular abscess affecting AV node (PPV of 88%!).
– Group B strep is rare as oropharyngeal flora (~5%), but causes an aggressive bacteremia.
– Here are the ACC/AHA and IDSA joint guidelines on endocarditis management, and a more recent review of the literature in NEJM.