Case Presentation: An 85-year-old Caucasian female with history of hypertension and coronary artery disease presented with syncope, leukocytosis and orthostatic hypotension. She denied chest pain, fever, abdominal pain, dysuria, diarrhea, seizure or previous similar episodes. Physical examination was unremarkable. Laboratory work-up showed leukocytosis of 23,000, eGFR of 27, creatinine of 1.69 and BUN of 15, urinalysis was positive for blood, protein and leukocyte esterase. Computed tomography (CT) of the head, chest x-ray, electrocardiography (EKG), troponin, lactate, ultrasound of the carotids and echocardiogram were unremarkable. Samples for urine and blood cultures were drawn and she received ceftriaxone and was admitted for further work up. CT of the abdomen and pelvis demonstrated a 1cm gallstone with no pericholecystic inflammation, a 2mm left renal calculus with moderate left hydronephrosis and perinephric fat stranding, the left ureter was markedly dilated down to the bladder with focal bladder wall thickening near the left uretero–vesical junction. On the second day, she had an episode of delirium, back pain and abdominal discomfort. One of two blood cultures grew Eggerthella lenta and ceftriaxone was switched to levofloxacin and later to cefepime. By the sixth day, the second blood culture tube was positive for Eggerthella lenta too but urine culture grew only skin and genital flora. The Urologist inserted a Foley catheter to relieve urinary retention and repeat urine culture and cystoscopy were done. Repeat blood and urine cultures were negative. Cystoscopy revealed bladder wall thickening, left-sided hydronephrosis and dilated left ureter with ureteropelvic junction narrowing. Bilateral ureteral stents were placed, and biopsies were taken. Biopsy showed keratinizing squamous mucosa without dysplasia. Patient improved after antibiotic change and she was discharged to complete 10 days of Cefepime.
Discussion: Eggerthella lenta (E. lenta) bacteremia is usually due to secondary translocation from the gastrointestinal tract and is often found in patients with malignancies, abdominal or genitourinary pathologies. Though cases with clinically significant poly-microbial or mono-microbial E. lenta infections have been documented, no guideline directed therapy for this organism is available. E. lenta is being increasingly recognized by newer lab technologies, but the availability of antimicrobial susceptibility testing for E. lenta remains restricted to specialized reference laboratories. In case reports, positive blood culture after a median of three days has been documented(1). Eggerthella lenta bacteremia should not be considered a contaminant until detailed evaluation of the patient has been conducted and other causes of the patient’s clinical condition found. In previous reports of a urinary source, treatment was with ceftriaxone and ciprofloxacin or vancomycin and metronidazole combination therapy(2). However, our patient appeared to have lack of response to ceftriaxone and was switched to cefepime with subsequent improvement.
Conclusions: This case had an unusual presentation with syncope, orthostatic hypotension and leukocytosis but no fever, nausea or dysuria. It emphasizes the need for a complete workup before concluding Eggerthella lenta bacteremia is a contaminant. More studies are needed to delineate the pathogenicity and mechanisms of antibiotic resistance for this organism.