Case Presentation: A 66-year-old male with end-stage renal disease on hemodialysis (HD), cervical spine stenosis with chronic constipation and previous stercoral colitis complicated by enterococcal bacteremia presented with two weeks of fevers and generalized weakness. The patient denied cough, runny nose, headaches, abdominal pain, diarrhea, or rash. He further denied recent procedures, hospitalizations, travel, or sick contacts. On admission, he was febrile to 39.1C. He had a 2/6 diastolic murmur at the right upper sternal border and pigmented lesions on bilateral palms. His labs were notable for a white blood cell count of 10.7k/mm3 and a negative respiratory viral panel. Imaging of the chest revealed a left pleural effusion. Blood cultures grew gram positive cocci in chains, and he was empirically treated with ceftriaxone and vancomycin for a suspected pulmonary infection. A transthoracic echocardiogram was ordered to rule out endocarditis and demonstrated moderate aortic regurgitation, which was new from four months prior. An aortic valve vegetation was later confirmed on transesophageal echocardiogram. Pleural fluid studies were consistent with an exudative effusion. The blood cultures speciated as Enterococcus faecalis, with pleural fluid also growing the same, for which a chest tube was placed. Infectious Disease (ID) was consulted and recommended treatment with ampicillin and ceftriaxone. Computed Tomography (CT) of the abdomen and pelvis suggested stercoral colitis as the source of infection. Due to persistent bacteremia, the patient was initiated on an aggressive bowel regimen for source control and ceftriaxone was changed to gentamicin with subsequent clearance of the bacteremia. He did not require repair or replacement of the valve. He was discharged on six weeks of gentamicin and vancomycin in combination with HD as well as an aggressive bowel regimen to prevent recurrence.

Discussion: Stercoral colitis is a relatively rare form of inflammatory colitis that results from severe constipation and leads to the formation of a fecaloma and, if left untreated, can lead to eventual necrosis and ulceration of the colon due to a compromise of the vascular supply. It is typically treated with manual disimpaction along with an aggressive bowel regimen, which needs to be continued after disimpaction to prevent recurrence. Untreated, stercoral colitis can lead to perforation and require surgical management. A review of the literature suggests, however, that there are few if any reports of bacteremia resulting in endocarditis as a complication of stercoral colitis. In this case, the patient’s prior admission for enterococcal bacteremia secondary to stercoral colitis and imaging again showing stercoral colitis without an alternative source led the team to believe that it was very likely to be the source of bacteremia again in this patient. Additionally, with disimpaction and an aggressive bowel regimen, presumably addressing the prior lack of source control, the patient did clear the bacteremia.

Conclusions: Although this appears to be an uncommon complication of stercoral colitis, it does highlight the importance of ensuring that patients with a history of stercoral colitis have clear instructions for an escalating bowel regimen in the outpatient setting to prevent recurrence and the complications that may result.