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| CASE REPORT |
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| Year : 2013 | Volume
: 31
| Issue : 3 | Page : 310-312 |
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Streptococcus pasteurianus septicemia
D Alex1, DF Garvin1, SM Peters2
1 Department of Pathology and Laboratory Medicine, Georgetown University Hospital/MedStar Health, Washington, USA
2 Department of Clinical Pathology and Laboratory Medicine and Division of Infectious Diseases, Clinical Immunology, Flow Cytometry and Molecular Diagnostics, Georgetown University Hospital/MedStar Health, Washington, USA
| Date of Submission | 24-Sep-2012 |
| Date of Acceptance | 08-Apr-2013 |
| Date of Web Publication | 25-Jul-2013 |
Correspondence Address:
S M Peters
Department of Clinical Pathology and Laboratory Medicine and Division of Infectious Diseases, Clinical Immunology, Flow Cytometry and Molecular Diagnostics, Georgetown University Hospital/MedStar Health, Washington
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0255-0857.115668
Streptococcus pasteurianus is part of the normal flora of the intestine. It has also been isolated from various infection sites. However, to date it has not been reported as a cause of fulminant septicemia and death. We report the post-mortem findings in a splenectomized hemophiliac patient with cirrhosis and concurrent human immunodeficiency virus (HIV), hepatitis B and hepatitis C infections.
Keywords: Group D Streptococcus, Streptococcus pasteurianus septicaemia, Streptococcus bovis
How to cite this article:
Alex D, Garvin D F, Peters S M. Streptococcus pasteurianus septicemia. Indian J Med Microbiol 2013;31:310-2 |
| ~ Introduction | |  |
Streptococcus pasteurianus is part of the normal flora of the intestine. It has also been isolated from various infection sites. However, to date it has not been reported as a cause of fulminant septicemia and death. We report the postmortem findings in a splenectomized hemophiliac patient with cirrhosis and concurrent human immunodeficiency virus (HIV), hepatitis B and hepatitis C infections. He was pronounced dead within 24 h of admission from a fulminant S. pasteurianus sepsis.
| ~ Case Report | | |
A 55-year-old white male with a history of hemophilia A, HIV and hepatitis B and C infections presented with an acute onset of dizziness to the emergency department of a tertiary care hospital. The symptoms progressed to abdominal and leg cramps followed by emesis, diarrhea and fever. On admission, he was hypotensive, dyspneic and required pressor support as well as oxygen via a 100% non-rebreather mask. There was no prior history of recent exposure to any other illness and no documented colonoscopy findings.
The patient's past medical history was significant for recurrent joint hemarthroses requiring multiple joint surgeries and portal hypertension with splenomegaly. He later developed refractory immune thrombocytopenic purpura for which he underwent a splenectomy 20 years ago. His HIV infection had been well managed with antiretrovirals and maintained stable CD4 counts. His last absolute CD4 count was 514 with an HIV-1 ribonucleic acid viral load less than 50 copies/ml (Range: 50-100,000 copies/ml). His antiretroviral medications were oral combivir (combination of zidovudine and lamivudine) 300 mg twice a day, oral viread (tenofovir) 300 mg once a day, oral erythromycin 500 mg once a day and bactrim (trimethoprim and sulfamethoxazole) one tablet 3 times a week. He was allergic to abacavir (ziagen) and penicillin.
His vital signs on admission revealed hypotension with a blood pressure of 72/34 mm of Hg and fever (38.5°C). His heart rate was 110/min with an oxygen saturation of 97% on room air. He was oriented to time, place and person. The pertinent positive findings included petechiae on his forehead, tachycardia and decreased bowel sounds.
He was started on vancomycin, avelox (moxifloxacin) and gentamicin in addition to his antiretroviral medications. Blood and urine samples were sent for culture and were found to be positive for S. pasteurianus on the vitek II (bioMerieux, Inc., Durham, N.C) with 99.9% probability.
In spite of aggressive treatment and resuscitative measures, he had significant bleeding from his intravenous line sites and developed overt disseminated intravascular coagulopathy for which he was given synthetic factor VIII. His condition deteriorated rapidly and he was pronounced dead within 24 h of admission. A limited postmortem examination was performed that showed ascites and macro- and micro-nodular liver cirrhosis. There were bilateral knee joint effusions which were aspirated. Cultures of the ascitic fluid and left knee joint aspirate were positive for S. pasteurianus, the same organism isolated pre-mortem from his blood and urine cultures.
| ~ Case Discussion | | |
S. pasteurianus is a newly classified bacterial species, previously known as Streptococcus bovis type II.2. [1] S. bovis is a part of the normal flora of the gastrointestinal system but can also be an opportunistic pathogen in immunocompromised patients. It is a known cause of bacteremia in patients with neoplasms of the colon. [2] There are also a number of reports of S. bovis septicemia in patients with chronic liver disease and cirrhosis. [2],[3]
Similar to other strains of S. bovis, S. pasteurianus has been isolated from various human infections and is a separate genospecies. [4] S. bovis biotype I and II are genotypically differentiated using 16S recombinant deoxyribonucleic acid (rDNA) based on their ability (biotype I) or inability (biotype II) to ferment mannitol. The manganese dependent superoxide dismutase gene (sodA) has been used to further differentiate similar strains of S. bovis obtained by 16S rDNA into type II.1 (mannitol and beta-glucuronidase negative and alpha-galactosidase positive) and type II.2 (mannitol negative, beta-glucuronidase and beta-mannosidase positive). [5]
To our knowledge, there is no reported case of S. pasteurianus bacteremia as a cause of fatal generalized septicemia. There are a few reported cases of S. bovis type II infections as a cause of central nervous system infection, endocarditis, septicemia and meningitis. [6]
It is well-known that colon cancer is associated with S.bovis sepsis. Although the pathogenesis has not been well understood, it has been speculated that S.bovis may be carcinogenic or may induce sepsis by undefined physical and chemical factors. [3],[4] Gold et al. [2] performed a retrospective analysis of patients with documented S. bovis infections and colon cancer. They concluded that there is an association between S. bovis bacteremia and colonic and extra-colonic malignancies. Ruoff et al. [7] showed that S. bovis type I was more commonly associated with gastrointestinal pathology than S. bovis type II. This emphasized the importance of isolation based on the type of S. bovis as they have different predilections for gastrointestinal disease and malignancy.
Different studies have shown the association between S. bovis bacteremia and cirrhosis in patients. A colonic source of sepsis was however not always identified in patients with advanced liver disease. Vilaichone et al. [8] have reported seven cases of spontaneous bacterial peritonitis caused by S. bovis in association with cirrhosis.
Most patients with spontaneous peritonitis present with fever and abdominal pain, as was seen in our patient. Spontaneous bacterial peritonitis in cirrhotic patients may be associated with impaired reticuloendothelial and bactericidal systems in the ascitic fluid. This impairment of function was most likely enhanced by the absence of a spleen in our patient.
The patient was also further immunocompromised as a result of his HIV infection. Although the infection was well managed with stable CD4 counts, he was probably immunocompromised by his co-morbid conditions. There were relatively few case reports of S. bovis bacteremia in HIV infected patients with or without a history of any invasive procedures. [1] S. bovis has also been reported as a rare cause of infection after joint arthroplasty. [9]
In summary, S. pasteurianus is a newly classified Group D streptococcus species that can cause extensive and fatal septicemia in immunocompromised patients. It is commonly associated with colon disease but can also occur in the absence of significant gastrointestinal pathology, particularly in immunocompromised populations. S. pasteurianus is sensitive to penicillin [9] with a few reported cases of erythromycin resistance. [10] It is therefore imperative to have a high index of suspicion for similar clinical scenarios to make early detection of cases possible. They can then be promptly treated for the S. pasteurianus septicemia with the use of antibiotics like penicillin.
| ~ References | | |
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| 2. | Gold JS, Bayar S, Salem RR. Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy. Arch Surg 2004;139:760-5.
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| 3. | Gonzlez-Quintela A, Martínez-Rey C, Castroagudín JF, Rajo-Iglesias MC, Domínguez-Santalla MJ. Prevalence of liver disease in patients with Streptococcus bovis bacteraemia. J Infect 2001;42:116-9.
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| 4. | Schlegel L, Grimont F, Ageron E, Grimont PA, Bouvet A. Reappraisal of the taxonomy of the Streptococcus bovis/Streptococcus equinus complex and related species: Description of Streptococcus gallolyticus subsp. gallolyticus subsp. nov., S. gallolyticus subsp. macedonicus subsp. nov. and S. gallolyticus subsp. pasteurianus subsp. nov. Int J Syst Evol Microbiol 2003;53:631-45.
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| 8. | Vilaichone RK, Mahachai V, Kullavanijaya P, Nunthapisud P. Spontaneous bacterial peritonitis caused by Streptococcus bovis: Case series and review of the literature. Am J Gastroenterol 2002;97:1476-9.
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| 9. | Apsingi S, Kulkarni A, Gould KF, McCaskie AW. Late Streptococcus bovis infection of knee arthroplasty and its association with carcinoma of the colon: A case report. Knee Surg Sports Traumatol Arthrosc 2007;15:761-2.
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