2277 Multiple Liver Abscesses Caused by Streptococcus Intermedius Bacteremia in the Setting of a Routine Dental Cleaning

Abstract

INTRODUCTION: Streptococcus intermedius is a member of the Streptococcus anginosus group, also referred to as the “Streptococcus milleri” group. The S anginosus group is part of the oral cavity and GI tract normal flora. S intermedius has been known to cause abscesses in various locations in the body, most commonly in the liver and brain, however this is uncommon in healthy individuals. We report the clinical case of an immunocompetent 21-year-old male found to have multiple hepatic abscesses associated with streptococcus intermedius in the setting of a recent dental cleaning. CASE DESCRIPTION/METHODS: Patient is a 21-year-old immunocompetent male who presented to the hospital with complaint of right upper quadrant pain, fevers, and chills. He underwent a routine dental cleaning 3 months prior. On admission, his vitals were BP 88/53 mmHg, HR 142 beats/minute, RR 41 breaths/min and temperature 38.7C. His exam was remarkable for right upper quadrant tenderness and splenomegaly. The remainder of his diagnostic evaluation revealed (a) leukocytosis of 16,000 cells/mm3 with left shift, (b) elevated creatinine of 2.66 mg/dl, (c) elevated alkaline phosphatase of 573 U/L, aspartate aminotransferase of 102 U/L and alanine aminotransferase of 65 U/L with a bilirubin of 1.8 mg/dl. Computed-tomography (CT) of the abdomen and pelvis demonstrated multiple right lobe hepatic abscesses with the largest measuring 7.3 cm. Two sets of blood and fluid cultures from an ultrasound guided aspiration returned positive for S. Intermedius. The patient underwent 2 subsequent drainage procedures for the larger lesion. The patient demonstrated remarkable clinical recovery and was discharged with a 6-week course of PO ertapenem therapy. Follow-up laboratory values demonstrated resolution of his hematological abnormalities, acute kidney injury and transaminitis. DISCUSSION: Although S. intermedius has been been associated with pyogenic liver abscesses, it typically occurs in the setting of immunocompromised states. This case was particularly interesting in that it occurred in an immunocompetent young male in the setting of routine dental cleaning 3 months prior. While other case studies have reported liver abscesses from S. intermedius after dental cleaning, typical latency is 1 month from the dental cleaning while much longer latency is noted in the reported case. This raises the question of how long after a dental cleaning a patient may have an increased risk of developing abscesses, even if the patient is thought to be immunocompetent.