2022, Number 2
Multiple abscesses in the thorax and abdomen by Streptococcus anginosus: case report and literature review
Full text
10.35366/109715
Language: English/Spanish [Versi?n en espa?ol]
References: 10
Page: 73-76
PDF size: 152.07 Kb.
ABSTRACT
Introduction: intra-abdominal abscesses present themselves mainly secondary to surgical intervention of an infectious site, such as an appendectomy, perforations, or trauma surgery. Case report: we present a case report of an intra-abdominal abscess in a male adult after laparoscopic gastric bypass. Results: days after laparoscopic intervention, a patient attends medical service with signs of infection, abscesses were found in abdomen and thorax. Streptococcus anginosus was identified as agent and treated successfully. Conclusions: new agents have been identified as infectious sources for abscess formation, with specific pathways of dissemination, Streptococcus anginosus should be suspected.INTRODUCTION
Intraabdominal abscesses are mainly generated from contaminated or dirty surgeries such as diverticulitis, appendicitis, intestinal perforations, and penetrating abdominal trauma, among others.1 Other causes of abdominal abscesses are those caused by bacterial translocation from contiguous foci, or hematogenous or lymphatic dissemination from a distant focus.2
The Streptococcus anginosus group (SAG) has three species (S. intermedius, S. constellatus, and S. anginosus). These microorganisms have low bacterial virulence and are generally found as oral and genitourinary bacterial flora.3 However, multiple reports in the literature demonstrate these organisms' ability to form distant abscesses by hematogenous dissemination.1
In this work, we report through the presentation of a clinical case in a private hospital in the State of Mexico, Mexico, in which a patient who had undergone laparoscopic fundoplication showed abscesses in the thorax and abdomen, where S. anginosus was identified. It also emphasizes the importance of detecting this pathogen, which has increased its incidence in recent years.
CLINICAL CASE
We present the case of a 51-year-old male patient diagnosed with gastroesophageal reflux disease, whose only comorbidity was obesity, scheduled for fundoplication by laparoscopy. Preclinical examinations within normal parameters revealed complex airway data reported by anesthesiology. A prophylactic antibiotic was administered consistent of ceftriaxone 1 g in a single dose. The surgery was successfully performed, and only three attempts for intubation were required without incident. On the first postoperative day, an esophagogram with a water-soluble contrast medium was performed, which showed the integrity of the digestive tract without leakage of the contrast medium into the abdominal cavity.
On the second postoperative day, the patient was discharged. Two days later, while receiving analgesic therapy with nonsteroidal anti-inflammatory drugs, he presented to the emergency department with a temperature of 39.5 °C and tachycardia of 115 beats per minute. Physical examination revealed a soft, depressible, non-painful abdomen, with no evidence of peritoneal irritation. The rest of the examination was normal. A thoracoabdominal computed tomography (CT) scan showed a basal consolidation in the left lung field and the expectoration culture reported Streptococcus anginosus. Treatment with broad-spectrum antibiotics, such as ceftriaxone, and metronidazole was initiated. On the third day, he started with anorexia, and it was decided to take a new CT scan identifying a 300 ml subhepatic abscess. It was decided to drain the abscess and wash the abdominal cavity by laparoscopy without incident. Five days later, he presented fever of 38.5 °C, so it was decided to perform a new imaging study identifying multiple abscesses in the thorax and abdomen, which were drained by CT-guided puncture without incident.
With favorable evolution, the patient was discharged five days later with improved symptoms, without fever or alarm data. Antibiotic treatment with imipenem and linezolid was continued, and the patient evolved satisfactorily.
DISCUSSION
Streptococcus anginosus (SAG), first described by Andrewes and Horder in 1906 as a variant of Streptococcus pyogenes, constitutes the S. anginosus family along with Streptococcus intermedius and Streptococcus constellatus, also known as the Streptococcus milleri group.4 Infections by these bacteria have reported significant variability in their clinical presentations.5 These organisms are microaerophilic, catalase-negative, gram-positive cocci that form tiny colonies and a characteristic caramel odor due to the production of the metabolite diacetyl when cultured on blood agar.4
These microorganisms are low-virulence bacteria that exist as commensals in the oronasal flora, gingival sulci, gastrointestinal tract, and urogenital tract of humans.6 S. anginosus can spread to the blood in individuals with poor oral hygiene in cases of oral infections such as gingivitis and dental abscesses that may develop after the loss of the mucosal unit. This can lead to infections manifesting mainly as brain and liver abscesses or peritonitis.1
Intra-abdominal abscesses usually develop due to abdominal surgery for pathologies such as diverticulitis and appendicitis or for biliary disorders, pancreatitis, or organ perforations. Penetrating abdominal trauma can also cause S. anginosus abscesses. Abscesses caused by infectious bacteremia reaching the abdomen from a distant source are rare.1
Several authors have reported cases of S. anginosus infection. J. Tomas describes the association of S. anginosus as the causative germ of a pancreatic abscess in a patient with poor oral hygiene after multiple dental extractions.2 J. Cooper describes a case of purulent pericarditis due to S. anginosus with contiguous subdiaphragmatic and hepatic collections, which resolved with initial subxiphoid pericardial drainage.4 G. Simone et al. report a single case of disseminated infection of the S. anginosus group with multiple pyogenic cerebral, hepatic, and pulmonary lesions.7
A retrospective systematic review of 52 episodes of infection in patients aged 0-18 years by M. Furuichi et al. describes the sites of infection associated with each SAG species among pediatric patients: skin and soft tissue (35%), gastrointestinal tract (21%), genitourinary tract (21%), head and neck (19%), and central nervous system (2%).8 S. anginosus is most frequently isolated from the genitourinary tract and in blood cultures.9 S. constellatus is responsible for most skin and soft tissue infections and abscesses, and S. intermedius is isolated mainly in head and neck infections and brain abscesses.8,9 Polymicrobial infections are the most common, and more than 70% of patients infected with S. anginosus and S. constellatus are co-infected with obligate anaerobes (Bacteroides spp).9
Susceptibility of S. anginosus to penicillin, ampicillin, cefotaxime, erythromycin, clindamycin, levofloxacin, and vancomycin has been reported.9 O. Kobo et al. analyzed the association between SAG species and the presence of pyogenic infection through a retrospective, observational cohort study between the years 2009 and 2015, concluding that S. intermedius has the most potential to cause infections involving abscess formation or other deep infections. S. constellatus and S. anginosus caused bacteremia without an associated pyogenic infection more frequently than S. intermedius.3
The acidic environment is one of the most common stressors for bacteria in infected tissues, so they have mechanisms to thrive even in these environments.10
S. anginosus has aciduric properties like those of S. mutans or S. pyogenes, so the acid tolerance of this microorganism can facilitate the infection of the oral cavity or gastrointestinal organs, causing chronic inflammation and consequently causing infective endocarditis and abscesses in various sites of the body including the thorax and abdomen as observed in the case.10
CONCLUSIONS
Species of the SAG group have been identified more frequently and recognized as emerging pathogens in the formation of disseminated infections by the hematogenous route.
However, although these species have been shown to exhibit various factors that promote their virulence, they have yet to acquire much interest from the medical and scientific community.
REFERENCES
AFFILIATIONS
1 Department of General Surgery, Hospital Ángeles Lomas.
2 Department of Anesthesiology, Hospital Ángeles Lomas.
3 Mexican School of Medicine, Universidad La Salle.
Ethical considerations and responsibility: the authors declare that they followed the protocols of their work center on the publication of patient data, safeguarding their right to privacy through the confidentiality of their data.
Funding: no financial support was received for this work.
Disclosure: the authors declare no conflict of interest in carrying out the work.
CORRESPONDENCE
Sebastián Guadarrama-Sistos Vázquez. E-mail: sebastian.guadarramasistos.v@gmail.comReceived: 07/27/2021. Accepted: 12/23/2022