Group B Streptococcus (GBS) Bacteremia Likely From Infected Vaginal Pessary Causing Epidural Abscess, Endocarditis, and Septic Embolic Stroke

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: GBS is a gram positive coccus that colonizes in the human gastrointestinal and genital tracts (1). The reported annual incidence of GBS infection in the general population of non-pregnant adults is between 4 and 8 per 100,000 (1,2,3). In population- based surveys, invasive GBS bacteremias are responsible for 2 to 9% of heart infections and 4% of central nervous system infections (3). Indeed, 20 to 60% of invasive GBS bacteremias are fatal (3). CASE PRESENTATION: A 75 year old female with a history of Diabetes presented with 1 week of body aches, an episode of fever, and 1 to 2 days of altered mental status. Vital signs were normal. Patient was oriented, but falling to sleep during the conversation. Positive physical examination findings included 4/5 motor strength in bilateral lower extremities. Laboratory evaluation showed leukocytosis at 16,800/ microliter. Patient was started on Vancomycin and Ceftriaxone after obtaining blood cultures. CT of the head and MRI of the spine did not show any acute pathology. Cerebrospinal fluid analysis showed nucleated cells as 311 (79% neutrophils), glucose as 133 and protein as 122. Blood cultures came back as positive for Penicillin sensitive GBS with MIC of < 0.12, so the antibiotics were changed to Penicillin. Patient continued to have persistent GBS bacteremia on repeated blood cultures, so Gentamicin was added. A Trans Esophageal Echocardiogram showed small vegetation on the aortic valve. Patient's daughter visited her mother a few days after admission and revealed that patient had been having significant discomfort from vaginal pessary for a few months. Repeated blood cultures did not grow any organisms after removal of vaginal pessary, and a culture of pessary grew rare GBS. Patient's mentation and lower extremity weakness significantly deteriorated over time. Repeat MRI of brain and spine revealed acute infarction of left posterior parietal region and epidural abscess extending from T 12 to L3. Patient was emergently taken to the operating room, and epidural abscess was drained. Patient completely recovered after finishing the course of antibiotics and rehabilitation. DISCUSSION: No case of GBS bacteremia leading to epidural abscess, endocarditis, and septic embolic stroke secondary to vaginal pessary has been reported so far. In our patient, the likely source of infection was vaginal pessary; however we could not completely conclude that source, as GBS colonizes in the genital tract. CONCLUSIONS: Despite new advancements in medical technologies, a medical practitioner should never ignore the importance of history and the physical examination. Reference #1: Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis. N Engl J Med. 2000;342(1):15. Reference #2: Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA. 2008;299(17):2056. Reference #3: A population-based assessment of invasive disease due to group B Streptococcus in nonpregnant adults. N Engl J Med. 1993;328(25):1807. DISCLOSURE: The following authors have nothing to disclose: Mohana Krishna Loya No Product/Research Disclosure Information