the lancefield group g beta - hemolytic streptococci ( ggs ) have been recognized as pathogens causing serious infections in humans , although ggs can have a commensal relationship when present on the skin , pharynx , intestinal tract , and vagina.1 the major pathological conditions predisposing ggs infections include malignancy , alcoholism , cardiovascular disease , diabetes mellitus , bone and joint diseases , and cirrhosis of the liver .
we report a rare case of endogenous endophthalmitis caused by streptococcus equisimilis , a ggs organism .
a 74-year - old woman became confused in her daily living , and the confusion was concomitant with a high - grade fever on april 29 , 2008 .
she was admitted to a local hospital on the following day and was given intravenous ceftriaxone for 9 days .
she had a history of cardiac and brain infarctions and was at the postoperative stage of uterine cancer .
ggs was detected in cultures of her blood sample and she was suspected to have infective endocarditis .
although the hospital staff had noticed a moderate swelling of her left eyelid since may 1 , 2008 , an ophthalmologist did not examine her until she was referred to us on may 9 , 2008 .
physical examination showed the patient to be a very ill woman with a body temperature of 38c .
her left eyelids were swollen , and a moderate degree of conjunctival infection with chemosis was observed in her left eye .
transthoracic echocardiography disclosed a mobile mass associated with the mitral valve with moderate valvular regurgitation ( figure 1 ) .
laboratory tests demonstrated an elevated leucocyte count of 11850/l with 82% of polymorphonuclear cells , a c - reactive protein level of 10.65 mg / dl , lactate dehydrogenase level of 519 iu / l , amylase level of 175 iu / l , and brain natriuretic peptide level of 450.0 pg / ml .
she was immediately hospitalized and on the same day ( may 9 , 2008 ) underwent emergency mitral valvuloplasty and both intravitreal and subconjunctival injections of both 1 mg / ml vancomycin and 1 mg / ml meropenem .
after the surgery , she was treated with topical antibiotics ( levofloxacin ) and ointment ( oflx ) for approximately 1 month , intravenous gentamicin ( 200 mg / day ) , and intravenous penicillin g potassium ( 240,000 iu / day ) for 9 days .
her general condition and ocular inflammation gradually improved with the medical therapy . however , her best - corrected visual acuity remained at light perception .
subsequently , cultures from both anterior chamber and vitreous biopsy specimens grew s. equisimilis , which was sequenced by polymerase chain reaction .
the s. equisimilis was found to be susceptible to penicillin g , ampicillin , sulbactam sodium / ampicillin sodium , imipenem / cilastatin , levofloxacin , and vancomycin , and was resistant to erythromycin and clarithromycin .
s. dysgalactiae subsp . equisimilis hosts variants within the lancefield group a , c , l , and g carbohydrates , and was recently determined by gene sequencing to be a subspecies of group g of s. equisimilis .
exogenous ggs endophthalmitis has been reported following cataract surgery , penetrating keratoplasty and trabeculectomy.2 on the other hand , endogenous ggs - related endopthalmitis is extremely rare.1 so far , there have been only 8 cases of endogenous ggs - related endophthalmitis;35 4 cases associated with endocarditis , 1 with cellulites of the foot , 1 with facial trauma , 1 with an abscessed tooth , and 1 of unknown origin .
we demonstrated a case of an endogenous ggs - related endophthalmitis where s. equisimilis was first identified from both anterior chamber and vitreous biopsies , and where identification was also first made by polymerase chain reaction .
the first - line therapy of s. equisimilis - induced infections is penicillin . besides penicillin ,
s. equisimilis was sensitive to all of the antimicrobial agents we administered . in our case , we suggest that a delay in the diagnosis would have worsened the general conditions of the patient , and would then lead to a poorer prognosis . at present
, the efficacy of immediate ocular therapies including vitrectomy and intravitreal antibiotics against ggs - related endogenous endophthalmitis is still controversial.3 only further investigations will answer this question .
 we report a rare case of endogenous endophthalmitis caused by streptococcus equisimilis . a 74-year - old woman with endocarditis developed endogenous endophthalmitis . 
 the patient underwent emergency mitral valvuloplasty , and intravitreal and subconjunctival injections of vancomycin and meropenem . 
 after the surgery , she was treated with topical antibiotics , ointment , intravenous gentamicin and intravenous penicillin g potassium . 
 the causative organism was identified as s. equisimilis . 
 s. equisimilis should be considered as a pathogen that can cause severe endogenous endophthalmitis . 