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Abstract

SESSION TITLE: Critical Care 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Streptococcus Agalactiae, also known as Group B Streptococcus (GBS) is a gram-positive bacteria that has been increasingly recognized to cause a broad spectrum of infections in the non pregnant adult population. GBS is considered to be a part of the human microbiota that colonizes the genitourinary and gastrointestinal tract, S.Agalactiae can also cause severe invasive infections in adults. We report a case of acute descending mediastinitis as a complication of septic arthritis of the sternoclavicular (SC) joint due to hematogenous spread of S.Agalactiae in a patient with a rectovaginal fistula and a presacral abscess. CASE PRESENTATION: 50 year old female with recurrent stage IV rectal adenocarcinoma who is status post extensive tumor resection including low anterior resection with end colostomy, complicated by formation of a rectovaginal fistula, who presented with a new presacral stump abscess, urinary tract infection, Streptococcus Agalactiae bacteremia and clinical and radiographic evidence of right sternoclavicular joint septic arthritis, osteomyelitis of clavicle and multiple abscesses superior and posterior to the SC joint with enhancement extending to the superior mediastinum on chest MRI. Patient was adequately resuscitated and started on antibiotics. She was immediately taken to the operating room (OR) for immediate debridement and washout of chest wall abscesses and resection of the right sternoclavicular joint and partial right clavicle, and first rib and manubrium ostectomy. OR tissue cultures grew S.Agalactiae. She proceeded to have presacral abscess drained, which also grew S. Agalactiae. Patient performed well and was later discharged home to complete her 6 week course of antibiotics. DISCUSSION: Acute descending mediastinitis is a life threatening condition that carries high mortality if not recognized promptly. To our knowledge, two case reports in the current literature have described GBS as a cause of mediastinitis. It has been described as a late complication of abortion and a deep neck abscess. Diabetes has been hypothesized as a risk factor for severe GBS infection. In our patient, the presence of a rectovaginal fistula allowed the translocation of S.Agalactiae from the genitourinary tract in the pelvis. We suspect that the presacral stump abscess was the source of her GBS bacteremia which lead to septic arthritis of her right SC joint, osteomyelitis of the right clavicle and progressed to acute descending mediastinitis. The rarity of this association and the unexpected microbiologic nature of the patient’s mediastinitis prompted this report. CONCLUSIONS: Patients with rectovaginal fistulae may be at increased risk of Group B Streptococcus translocation to the pelvis, which may cause hematogenous spread and further invasive infections. Reference #1: Rapp C, Debord T, Breton G, Imbert P, Roué R. [Streptococcus agalactiae mediastinitis, a late complication of abortion]. Presse Med. 2002;31(16):744. Reference #2: Yoshii Y, Shimizu K, Watanabe S, Takagi M, Kuwano K. [A case of descending necrotizing mediastinitis caused by infection with Streptococcus agalactiae in a patient with diabetes mellitus]. Kansenshogaku Zasshi. 2012;86(6):768-72. Reference #3: Kuhtin O, Schmidt-rohlfing B, Dittrich M, Lampl L, Hohls M, Haas V. [Treatment Strategies for Septic Arthritis of the Sternoclavicular Joint]. Zentralbl Chir. 2015;140 Suppl 1:S16-21. DISCLOSURES: No relevant relationships by christina al malouf, source=Web Response No relevant relationships by Martine Al Malouf, source=Web Response No relevant relationships by Xavier Jimenez, source=Web Response