A previously healthy 19-year-old woman presented to the emergency department with one week of abdominal pain, bloody diarrhea, and fever. Two weeks prior, she reported a non-specific flu-like illness. On admission, she was febrile, tachycardic, and hypotensive. She had a toxic appearance and a firm, diffusely tender abdomen. She had no oropharyngeal, pulmonary, or genital findings, and the remainder of her examination was normal. Initial laboratory results revealed a leukocytosis of 22.5×109/L and an elevated lactate of 2.0 mmol/L. Computed tomography of the abdomen and pelvis demonstrated ascending colonic wall thickening and fat stranding, consistent with colitis.
There was concern for infectious colitis versus new inflammatory bowel disease (IBD). Antibiotics were initiated, and gastroenterology was consulted for evaluation of possible IBD. She was given intravenous fluids and supportive care.
To the team’s surprise, blood cultures returned positive for Group A Streptococcus (GAS). Given her persistent hypotension, there was concern for toxic shock syndrome and antibiotics were broadened to vancomycin, piperacillin-tazobactam, and clindamycin. After 48 hours of broad-spectrum antibiotics, surveillance blood cultures remained negative, and the patient’s blood pressure, abdominal pain, and bloody stools improved. Routine infectious stool studies returned negative and there was no other obvious source for GAS bacteremia. Colonoscopy was not performed due to increased risk of perforation in the setting of acute inflammation.
She completed a 14-day course of intravenous penicillin G with resolution of her symptoms. Ultimately, she was believed to have acute GAS infection of the colon, perhaps precipitated by an initial streptococcal infection two weeks prior.
Discussion:
Hospitalists frequently encounter infectious colitis and streptococcal infections but rarely concurrently. GAS is a well-known cause of perineal, perianal, and anal disease in pediatric populations. In adults, however, there are only rare case reports of GAS-associated colitis. If present, history of pharyngitis or impetigo can help raise suspicion. Diagnosis of gastrointestinal GAS infection can be made via histology, occasionally with visualization of bacteria in colonic tissue. It is unclear if GAS colitis is caused by direct bacterial invasion of colonic mucosa or by toxin-mediated effects. Given its rarity, the prognosis of gastrointestinal GAS infection is unclear. Our patient experienced a complete recovery with appropriate antibiotic therapy.
Conclusions:
Streptococcal infection can present in adults as acute abdominal pain and can mimic other forms of infectious colitis and inflammatory bowel disease. Although rare, it is important to consider gastrointestinal GAS infection in a patient with abdominal pain and GAS bacteremia.