A 55–year–old man with a history of eosinophilic esophagitis requiring repeated stricture dilations presented to the Emergency Department with headache, fevers, nuchal rigidity, nausea, vomiting, photosensitivity, and myalgias. These symptoms followed a recent esophagogastroduodenoscopy (EGD) for esophageal impaction of chicken four 4 days prior to presentation. The procedure was uncomplicated and performed approximately three 3 hours after ingestion of the chicken. A stricture was noted but not dilated due to surrounding inflammation. The patient developed mild myalgias the evening of the procedure, but otherwise felt well. Two days later, he presented to the ED and was febrile to 38.5 degrees C with significant nuchal rigidity and photophobia on exam. A lumbar puncture was performed with cerebrospinal fluid (CSF) analysis showing an elevated white blood cell count of 2,438 per mm3 (91% neutrophils) and elevated protein of 195 mg/dL. Gram stain demonstrated gram–positive cocci. Blood cultures were drawn, and the patient was given empiric antimicrobial coverage with vancomycin and ceftriaxone upon admission. The patient quickly showed subjective improvement in symptoms and remained afebrile by hospital day #2. CSF cultures returned on hospital day #3 growing Streptococcus salivarius, and the patient’s antibiotic regimen was narrowed to ceftriaxone 2 grams IV q 12 hours with plan for a fourteen–day course by PICC line. Blood cultures remained negative. The patient was discharged home on hospital day #4 and was subsequently seen in outpatient follow up by the Infectious Disease service on treatment day #11 with complete resolution of presenting symptoms.
Streptococcus salivarius is a common inhabitant of the human oral mucosa and only rarely causes invasive infections. Viridans group streptococci are rarely associated with meningitis and account for <1% of all cases of purulent meningitis. There have been approximately sixty case reports of S. salivarius meningitis; however, most are due to procedures involving the meninges such as craniotomy, placement of ventricular catheters/shunts, lumbar punctures, or complicated head trauma. Although bacteremia following gastrointestinal procedures has been well documented, its incidence is low (4.2% with EGD), and its course is usually transient without major clinical sequelae. Furthermore, researchers have found that bacteremia does not correlate with the performance of biopsy or the type of mucosal abnormality present.
We report this case of bacterial meningitis to heighten physicians’ awareness about potential nosocomial causes, including this rare but significant complication from the commonly performed EGD.