CASE PRESENTATION: A 57 year old female with alcohol abuse presented with altered mental status. She was tachycardic, hypotensive, tachypneic, and febrile. Initial labs showed a leukocytosis and lactic acidosis. Due to persistent hypotension after fluid resuscitation, norepinephrine was started. A noncontrast head CT was negative. The patient rapidly deteriorated into hypoxic respiratory failure requiring intubation. A portable chest x-ray showed a dense consolidation occupying most of the right lung. Blood, sputum, and urine cultures were obtained. The patient was started on vancomycin, ceftriaxone, and ampicillin for severe community acquired pneumonia and concern for meningitis. A lumbar puncture was performed, cerebrospinal fluid labs showed a WBC of 1943 (70% neutrophils), glucose 14, protein 224, and gram + cocci in chains, confirming bacterial meningitis. Gram stains from blood and sputum resulted as gram + cocci in chains and cultures confirmed pan-sensitive S. pneumoniae. Antibiotics were de-escalated to ceftriaxone. After 7 days of antibiotics, all the patient's parameters and labs improved except for poor mental status. A brain MRI showed multiple areas of acute infarction suspicious for septic embolic. A transesophageal echocardiogram revealed filamentous structures on the mitral valve, confirming bacterial endocarditis. Gradually the patient’s mental status improved. She was discharged to a rehabilitation center to complete 4 weeks of ceftriaxone.