A Man with Fever and Bacteremia

Posted by • July 10th, 2015

Man-with-Fever-and-Bacteremia-PITIn the latest Case Record of the Massachusetts General Hospital, fever developed in a 37-year-old American man living in Vietnam. He was transferred from a local infirmary to an international hospital. A blood culture grew Streptococcus constellatus; fever resolved with antibiotics. The patient was transferred for further evaluation.

The finding of Streptococcus constellatus bacteremia mandates a search for an abscess.

Clinical Pearls

What is the most common type of visceral abscess?

Liver abscess is the most common type of visceral abscess, accounting for about 13% of intraabdominal abscesses. Risk factors include diabetes, hepatobiliary or pancreatic diseases, or Klebsiella pneumoniae infection due to host factors (e.g., glucocorticoid therapy, alcoholism, chronic disease, or neoplasia). The mortality rate associated with a liver abscess can be as high as 12%.

What is the distinguishing feature of S. constellatus?

S. constellatus is a member of the S. milleri group, which is a member of the viridans group of streptococci. S. milleri are commensal organisms; they are usually not pathogenic. S. constellatus is part of the normal flora of the human oral cavity. Despite the usual commensal status of S. constellatus, the bacteria is considered to be a true pathogen when it is found in the blood. It is a facultative anaerobe whose distinguishing feature is its ability to cause abscesses.

Morning Report Questions

Q: What anatomic sites may be infected by S. milleri?

A: S. milleri infections usually affect the mouth and throat, causing dental, peritonsillar, or sinus abscesses. Spread of abscesses to deep spaces can lead to septic thrombophlebitis of the jugular vein (Lemierre’s syndrome). Bacteremia can occur, leading to metastatic abscess formation in the lung, brain, liver, kidney, and other tissues. Endocarditis can also occur, usually in a patient with an abnormal heart valve.

Q: What are some of the reported sequelae of fish-bone ingestion?

A: There have been many case reports of fish-bone ingestion in the literature. Most of these cases occur in Southeast Asia, because some of the fish there have smaller bones, as compared with the fish in Western regions. A common complication is a liver abscess, but esophageal perforation with deep-neck infection, a thyroid abscess, and tongue and mediastinal abscesses have also been reported. A 1999 case report from Japan included a review of seven previously reported cases of fish-bone ingestion. Hepatic abscess had occurred in all cases; in four cases, the fish bones penetrated the stomach wall (three penetrated the left lobe of the liver and one penetrated the right lobe), and in three cases, the fish bones pierced the duodenum. The case report from Japan also noted that few patients were aware that they had ingested a fish bone.

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