S2749 Streptococcus intermedius Liver Abscesses in a Patient Presenting With Fatigue

Abstract

INTRODUCTION: Streptococcus intermedius is part of the Streptococcus milleri group. It can be found as part of the normal flora of the oropharyngeal cavity and gastrointestinal tract. Although rare, Streptococcus intermedius can cause hematogenous infection in addition to liver abscesses in healthy patients. We describe a case of Streptococcus intermedius liver abscesses and bacteremia in a patient who presented with fatigue. CASE DESCRIPTION/METHODS: A 73 year old male patient with a past medical history of coronary artery disease and hypertension presented to the hospital with progressively worsening weakness and fatigue in addition to generalized abdominal pain. Patient had a previous history of resolved hepatitis C infection. There was no signs of hepatic decompensation or weight loss. On presentation, patient’s vital signs were within normal limits. Physical exam was remarkable for generalized abdominal tenderness. Labs were significant for a WBC of 12.6 × 109/L and INR of 1.4. Liver function tests were significant for an ALT of 50 U/L and a total bilirubin of 3.1 U/L. A CT of the abdomen and pelvis showed nonspecific sigmoid colitis or diverticulitis. Blood cultures were taken. Patient was started on appropriate antibiotics for suspected diverticulitis. Blood cultures were later positive for Streptococcus intermedius. Liver ultrasound showed multiple small hypoechoic lesions in the liver, and signs of hepatic steatosis. MRI of the abdomen was suggestive of multifocal hepatic abscesses. He was treated with IV ceftriaxone for six weeks followed by Augmentin for 2 two weeks. Follow up MRI one month after initial presentation showed decrease in the size of liver abscesses. Complete resolution of abscesses was seen on MRI a month later. DISCUSSION: Although it is uncommon, Streptococcus intermedius is notorious for causing abscesses with reported cases of brain, lung, and liver abscesses in the literature. It is likely that the bacteremia occurred first followed by abscess formation. The source of the bacteremia is unclear though it is most likely from a GI source in the setting of colitis seen on CT scan in this case. Patient is scheduled for colonoscopy to look for malignancy as the nidus for this infection. He will also undergo cardiac echo to rule out endocarditis although rare. There should be high suspicion for liver abscesses in patients with Streptococcus intermedius bacteremia. Timely diagnosis is important as untreated pyogenic liver abscesses can be fatal.