Case Presentation:

A 42–year–old Hispanic male, butcher by occupation with a history of alcohol abuse, presented with a 6–day history of epigastric abdominal pain, diarrhea and fevers. Vital signs showed fever and mild tachycardia. Laboratory analysis showed white blood count of 9.3, hematocrit 44, platelets 100, 19% bands, lipase 510. Ultrasound of the abdomen showed evidence of pancreatitis. The patient was admitted for management of acute pancreatitis and potential infection. On hospital day 2, the patient continued to be febrile, tachycardic and faint cardiac murmur was noted. Blood cultures grew Group G Streptococcus (GGS), and the patient was started on intravenous (IV) antibiotics. A transthoracic echocardiogram (TTE) showed aortic valve thickening with leaflet calcification and possible vegetation. A transesophageal echocardiogram was performed showing bicuspid aortic valve with thickening and shaggy appearance consistent with endocarditis and a small valve perforation in the junction of non–coronary and left coronary cusp. Cardiology and cardiothoracic surgery was consulted and decided to continue medical management with antibiotics, as patient did not meet criteria for emergent surgery. Hospital course was complicated by melena and symptomatic anemia. An endoscopy was performed and showed a nonbleeding gastric ulcer. On hospital day 7, the patient began to complain of visual deficits in his left eye. A MRI/MRA of the brain showed lesions in the right occipital lobe suggestive of embolic phenomenon but no evidence of mycotic aneurism. Skin examination revealed a presence of splinter hemorrhage on one of the fingers. The patient remained hemodynamically stable, and repeated TTE showed no worsening of left ventricular function. Repeated blood cultures showed no growth. The patient was discharged home on IV antibiotics and planned for elective valve replacement.

Discussion:

Bacteremia with subsequent endocarditis caused by GGS is uncommon and serious infection causing high morbidity and mortality, and it can be extremely destructive to the native heart valves. Studies have shown that almost half of patients diagnosed with GGS bacteremia will develop endocarditis. GGS were found to colonize pharynx, skin, and gastrointestinal and female genital tracts. Domestic animals are also known for harboring this microorganism. Bacteremia caused by GGS has also been related to underlying conditions, such as alcoholism, malignancy, IV substance abuse, diabetes mellitus, or breakdown of the skin. A gastrointestinal and skin source was the most presumptive in this patient, who was diagnosed with gastric ulcer disease and was a butcher by occupation.

Conclusions:

Infectious endocarditis caused by GGS is rare and serious condition that has been reported with increasing frequency in recent years. Therefore hospitalists should obtain a detailed history and physical exam followed by an early echocardiogram and aggressive treatment.