STREPTOCOCCUS BOVIS SEPTICEMIA FOLLOWING ISCHEMIC COLITIS AND UNDERLYING LIVER DYSFUNCTION

Abstract

The Case: A 60 years old black female was brought to the hospital after being found unresponsive at home. She was noted to have some abdominal pain with diarrhea and appeared somewhat lethargic and drowsy a day prior to presentation. She had a history of bronchial asthma, hypertension, hepatitis C and depression. She smoked crack cocaine one day before arrival. In ED she was hypotensive and intubated for airway protection. Her abdominal was soft, non tender, with active bowel sounds. Stool was hemeoccult positive. Other systems were otherwise unremarkable. After stabilizing the patient empiric antibiotics were initiated. Laboratory Data: A total WBC count was 13,900/mm3 with 54 bands. BUN and creatinine levels were 70 and 5.8, respectively. AST 308, ALT 110, Alkaline phosphatase 138, Creatine kinase 2266, Troponin I 4.4 and Ck-MB Mass 35. Urine drug screen was positive for cocaine. Blood culture grew S. bovis in both aerobic and anerobic bottles. Echocardiogram was unremarkable. Hospital Course: On the 3rd hospital day the patient developed abdominal distention with diminished bowel sounds. Lower small bowel obstruction pattern was seen in abdominal CT. Colonoscopic evaluation showed swelling around the ileocecal valve with areas of patchy mucosal edema and erythema, interspersed with areas of normal appearing mucosa. Two days later patient underwent right hemicolectomy. Histopathologic examination of the surgical specimen was compatible with Ischemic colitis. Her post-op course was unremarkable and she was discharged home after 2 weeks of hospital stay. Discussion:S. bovis is a constituent of normal colonic flora only in 2.5 to 15% of individuals and fecal carriage can be an early clue to the presence of serious and clinically unexpected colonic disease. The association between S. bovis bacteremia and carcinoma of the colon has been appreciated for many years. The association with other GI pathology is a much less reported entity. A triad of S. bovis bacteremia, colonic pathology, and liver disease is presented here. We assume chronic hepatitis C might have caused intrahepatic blood shunting and impaired clearance of the bacteria by reticuloendothelial system. Conclusion: In the setting of S. bovis bacteremia a screening for underlying liver disease should be performed along with a large bowel survey for cancer as well as colonic ulcerations.