MASSIVE LUNG ABSCESS DUE TO STREPTOCOCCUS INTERMIDIUS IN AN IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Streptococcus intermidius (SI) is a gram positive bacterium which is a part of the oral, respiratory, urogenital as well as gastrointestinal flora. We present a case of a massive lung abscess with severe acute respiratory distress syndrome (ARDS) requiring veno-venous extracorporeal membrane oxygenation (V-v ECMO) in an immunocompetent patient. CASE PRESENTATION: A 54-year-old male patient with past history of diabetes mellitus presented with shortness of breath and fever. The patient was found to have tachycardia, tachypnea and low blood pressure. A Chest radiograph showed a large dense appearing mass like lesion in the right lung (Figure 1)and a CT scan was performed. The scan showed a 14 cm lung abscess with dense necrotic material (Figure 2&3). The patient decompensated and required emergent intubation with a bedside drainage of the lung abscess and placement of a chest tube. Cultures on the aspirated material grew Streptococcus Intermidius. The patient was started on antibiotics Cefepime and Metronidazole. The patient developed severe ARDS and required the V-v ECMO. The V-v ECMO was explanted after 6 days. Over the course of his stay, the chest tube continued to drain purulent material with a continued air leak. The patient underwent a right lung decortication by a video assisted thoracoscopic surgery (VATS). Due to the prolonged intubation and a likelihood of failure of weaning a tracheostomy was performed. The patient was discharged to a rehabilitation facility with a month long course of Cefepime and Metronidazole. On a 12 month follow up the patient was doing well and the tracheostomy had been successfully decanulated. DISCUSSION: Streptococcus intermidius is a gram positive bacterium that belongs to the Streptococcus Millieri group (SMG). Streptococcus intermidius is usually associated with infections of the head, neck and respiratory tract and have a tendency to cause abscesses (1). Infections with SI a commoner in individuals with uncontrolled or undiagnosed diabetes, malignancy or intravenous drug use. Individuals with poor oral hygiene and dental caries are also at risk for getting SI infections (2). Multiple sites for infections are reported in literature including brain, lung, liver and head /neck region abscesses. A multiplex polymerase chain reaction (PCR) may aid in early detection of SI, while cultures can take over a week to grow. A study of the antibiotic sensitivities of SMG showed excellent susceptibility to Penicillin, Ampicillin and Ceftriaxone (3). However, penetration of the drugs into the abscess and necrotic material remains poor and surgical drainage and decortication is usually required. CONCLUSIONS: Streptococcus Intermidius is an important cause of empyema, early diagnosis and treatment is imperative to limit significant morbidity and mortality. Reference #1: Reddy S, Singh K, Hughes S. Liver Abscesses Caused by Streptococcus intermedius in an Immunocompromised Patient. Cureus. 2018;10(1):e2107. Published 2018 Jan 24. https://doi.org/10.7759/cureus.2107 Reference #2: Ramhmdani S, Bydon A. Streptococcus intermedius: an unusual cause of spinal epidural abscess. J Spine Surg. 2017;3(2):243-249. Reference #3: Tracy M, Wanahita A, Shuhatovich Y, Goldsmith EA, Clarridge JE, Musher DM. Antibiotic susceptibilities of genetically characterized Streptococcus milleri group strains. Antimicrob Agents Chemother. 2001;45(5):1511-4. DISCLOSURES: No relevant relationships by Yizhak Kupfer, source=Web Response No relevant relationships by Ravikaran Patti, source=Web Response No relevant relationships by Vignesh Ponnusamy, source=Web Response No relevant relationships by Chanaka Seneviratne, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by Parita Soni, source=Web Response No relevant relationships by Taek Sang Yoon, source=Web Response