Case Presentation: A 37 year old woman with past medical history of septic shock secondary to urinary tract infection (UTI), systemic lupus erythematosus treated with oral prednisone 10 mg/day, functional quadriplegia due to transverse myelitis, chronic sacral decubitus ulcers, chronic indwelling urinary catheter, morbid obesity, hypertension, and diabetes mellitus type 2 presented to the emergency department with respiratory failure requiring intubation, hypotension, bradycardia, and encephalopathy. Because EKG revealed sinus bradycardia with ST elevations inferiorly, shock was presumed to be cardiogenic versus septic in origin. She was treated with intravenous fluids, pressors, antibiotics, and underwent left heart catheterization, which was negative. Laboratory data was significant for elevated lactic acid and creatinine, leukocytosis, and urinalysis consistent with UTI with Gram-negative rods and fungi seen on smear. CXR showed no infiltrates and respiratory gram stain and culture were negative. Blood cultures became positive for Gram-positive bacilli, thus vancomycin, piperacillin/tazobactam and fluconazole were continued. Hemodynamics stabilized, lactic acid normalized, and renal function returned to baseline. Because of urethral erosion, suprapubic catheter was placed. CT of abdomen and pelvis demonstrated left adnexal complex fluid collection (5.0 x 6.8 x 5.9 cm) concerning for malignancy versus tubo-ovarian abscess (TOA). Gynecology recommended against drainage with follow-up outpatient evaluation.
Blood cultures grew Lactobacillus acidophilus in the anaerobic bottles. Repeat cultures drawn on hospital day 3 were negative. Urine culture grew E. coli and Candida albicans. TEE was negative for vegetations and trans-vaginal ultrasound re-demonstrated the left adnexal cystic and solid mass without change. The patient was discharged to a skilled nursing facility to complete the remaining IV antimicrobial treatment with gynecologic oncology outpatient follow-up arranged prior to her discharge.
Discussion: Lactobacillus is a known commensal organism, which can be found in the mouth, GI tract, and female GU tract. When seen in blood cultures, it is frequently thought to be a contaminant. Rarely, it can be a true pathogen so that with a clinically correlated source of infection, its presence should not be ignored since morbidity and mortality can be high without appropriate treatment. Lactobacillus bacteremia is most commonly reported in immunocompromised patients associated with probiotic use, pyelonephritis or ischemic colitis. Antimicrobial resistance is common so identification and susceptibilities are key to success in treatment. We report an immunocompromised woman with septic shock secondary to Lactobacillus bacteremia with genitourinary source of infection.
Conclusions: Lactobacillus is a commensal organism of the mouth, GI tract, and female GU tract that can rarely be a true pathogen in the proper clinical setting. Clinicians should not dismiss this organism as a “contaminant” since prompt recognition and appropriate treatment can be lifesaving. Risk factors, antimicrobial susceptibilities and propensity for mortality will be discussed.