Case Presentation: A 55-year-old Hispanic male with PMH of hypertension presented to the emergency department (ED) with a 2-week history of flu-like symptoms including malaise, fever and chills, anorexia, dry cough and night sweats. In the ED he was found to be lethargic, short of breath, and had abdominal distention accompanied by urinary and bowel incontinence. Family denied any tick bites, sick contacts, recent travel, with no other relevant medical or surgical history. Vital signs on presentation showed a blood pressure of 83/46mmHg, temperature of 105.5 °F, and heart rate of 112 BPM. Laboratory test detected a white blood cell count of 12.41 K/uL with a left shift and no bands, and transaminitis with AST (834 u/l) ALT (1,859 u/l), Alkaline phosphatase (134 u/l). The chest x-ray showed right lower lung atelectasis. The patient was intubated for airway protection, started on broad spectrum antibiotics and received IV fluid resuscitation. Despite these interventions he continued to deteriorate and was admitted to ICU for septic shock. A CT abdomen pelvis with IV contrast showed several hypo enhancing masses in the right hepatic lobe, largest measuring 10.2 x 8.9cm. 2 sets of blood cultures were positive for Beta Streptococcus group F. The patient was stabilized in the ICU and underwent laparoscopic drainage of the liver abscess and fluid collections by surgery. Cultures from aspirated material grew beta-hemolytic group F streptococcus and Streptococcus Anginosus. The patient cleared the gram-positive bacteremia, and all of his symptoms were resolved, but repeated CT scan of abdomen showed a persistent 5.8 x 5 x 6cm collection in the right hepatic lobe. He was discharged on Augmentin for a total of 3 weeks after drainage. At 6 months follow up, CT abdomen showed no evidence of residual hepatic collection.
Discussion: Streptococcus Anginosus group specifically group F Strep. is an uncommon pathogen characterized by Pyogenic Liver abscesses (PLA). The incidence rate has increased in the last two decades, seen in males more frequently than females. Most abscesses are solitary and occur in the right lobe of the liver. Risk factors include diabetes, underlying hepatobiliary disease, and liver transplantation. These abscesses can result from portal vein pyemia (appendicitis, diverticulitis, colon cancer, inflammatory bowel disease. Clinical manifestations are fever, right upper quadrant pain, fatigue, nausea, weight loss and unusual cases progress to septic shock. Treatment is systemic antimicrobial therapy where most strains are susceptible to penicillin, aminopenicillins, and tetracycline. Combination with drainage techniques ensure a better outcome. This immunocompetent adult presented with nonspecific systemic symptoms, group F Streptococcus bacteremia and septic shock. Surprisingly, he was found to have multiple large hepatic abscesses from an uncommon organism with the lack of remarkable risk factors.
Conclusions: This case provides evidence that although rare, S. Anginosus can produce Pyogenic Liver Abscesses leading to bacteremia and septic shock, even in the absence of significant risk factors. Prompt identification of the causal organism is imperative to target pharmacologic treatment and reduce mortality.