Colonoscopy is mandatory after Streptococcus bovis endocarditis: a lesson still not learned. Case report

An international report on bacterial communities in esophageal squamous cell carcinoma

The incidence of esophageal squamous cell carcinoma (ESCC) is disproportionately high in the eastern corridor of Africa and parts of Asia. Emerging research has identified a potential association between poor oral health and ESCC. One possible link between poor oral health and ESCC involves the alteration of the microbiome. We performed an integrated analysis of four independent sequencing efforts of ESCC tumors from patients from high- and low-incidence regions of the world. Using whole genome sequencing (WGS) and RNA sequencing (RNAseq) of ESCC tumors from 61 patients in Tanzania, we identified a community of bacteria, including members of the genera Fusobacterium, Selenomonas, Prevotella, Streptococcus, Porphyromonas, Veillonella and Campylobacter, present at high abundance in ESCC tumors. We then characterized the microbiome of 238 ESCC tumor specimens collected in two additional independent sequencing efforts consisting of patients from other high-ESCC incidence regions (Tanzania, Malawi, Kenya, Iran, China). This analysis revealed similar ESCC-associated bacterial communities in these cancers. Because these genera are traditionally considered members of the oral microbiota, we next explored whether there was a relationship between the synchronous saliva and tumor microbiomes of ESCC patients in Tanzania. Comparative analyses revealed that paired saliva and tumor microbiomes were significantly similar with a specific enrichment of Fusobacterium and Prevotella in the tumor microbiome. Together, these data indicate that cancer-associated oral bacteria are associated with ESCC tumors at the time of diagnosis and support a model in which oral bacteria are present in high abundance in both saliva and tumors of some ESCC patients.

Streptococcus gallolyticus-related spinal epidural abscess

Spinal epidural abscess (SEA) is a surgical emergency if it causes paraplegia. Staphylococcus aureus and streptococci are the most common causes. Streptococcus gallolyticus has been reported to cause SEA only on three occasions earlier-all were associated with endocarditis or colonic malignancy. We report an older woman with diabetic ketoacidosis who presented with poorly localised back pain, fever and altered sensorium. Her lumbar puncture revealed frank pus, and MRI showed an SEA. She could not be weaned from mechanical ventilation post-surgical decompression, and she succumbed to ventilator-associated pneumonia. A triad of fever, back pain and neurological deficit should lead one to consider intraspinal suppuration. This report is the first S. gallolyticus-related SEA from India and the first in literature that was not associated with either endocarditis or colonic malignancy.

Fusobacterium nucleatum: More Than Just an Oral Anaerobe

Fusobacterium nucleatum is a strict anaerobe that is indigenous to the human oral cavity, where it coexists with more than 500 other species. It is associated with paranasal sinus, odontogenic, and pulmonary infections. In literature, cases of Fusobacterium nucleatum are rare. Here we report a case of a patient with multiple brain abscesses caused by Fusobacterium nucleatum. This case report looks to assist clinicians in determining the true etiology of this organism, which can change patient management based on the current literature review and similar case studies.

The Effect of Nomenclature Revision of Streptococcus bovis to Streptococcus gallolyticus on Subsequent Colon Cancer Screening

Background

Lack of awareness of the taxonomic revision from the familiar Streptococcus bovis to the less familiar Streptococcus gallolyticus may be associated with a decrease in recommended colon cancer screening in patients with bacteremia from this organism. This could subsequently lead to a delay in diagnosis or underdiagnosis of colon cancer and other serious underlying gastrointestinal diseases. The aim of this study was to determine whether the nomenclature change of S. bovis to S. gallolyticus resulted in decreased colon cancer screening.

Methods

This study was a retrospective, observational, nationwide analysis of patients who had positive blood cultures for S. bovis/S. gallolyticus from any Veterans Affairs Medical Center (VAMC) between January 1, 2002, and December 31, 2017.

Results

There was no difference in the primary end point of intent for colonoscopy between the S. gallolyticus and S. bovis groups (66.5% [117/176] vs 62.1% [624/1005], respectively; P = .26). The overall mortality rate was 33.8% among 1181 patients included in the study, with a significantly lower mortality in patients with evidence of intent for colonoscopy (29.6% vs 42.5%; P ≤ .001), gastroenterology (GI) consultation (29.8% vs 41.4%; P < .001), infectious diseases (ID) consultation (29.4% vs 39.0%; P = .001), or either consultation (31.9% vs 40.7%; P = .013), compared to those that did not.

Conclusions

There was no difference in colon cancer screening rates between patients with episodes of bacteremia reported as S. bovis and those reported as S. gallolyticus. Overall mortality was lower in patients who had ID consultation, GI consultation, or evidence of colonoscopy.

The Bacterial Microbiota of Gastrointestinal Cancers: Role in Cancer Pathogenesis and Therapeutic Perspectives

The microbiota has an essential role in the pathogenesis of many gastrointestinal diseases including cancer. This effect is mediated through different mechanisms such as damaging DNA, activation of oncogenic pathways, production of carcinogenic metabolites, stimulation of chronic inflammation, and inhibition of antitumor immunity. Recently, the concept of "pharmacomicrobiomics" has emerged as a new field concerned with exploring the interplay between drugs and microbes. Mounting evidence indicates that the microbiota and their metabolites have a major impact on the pharmacodynamics and therapeutic responses toward anticancer drugs including conventional chemotherapy and molecular-targeted therapeutics. In addition, microbiota appears as an attractive target for cancer prevention and treatment. In this review, we discuss the role of bacterial microbiota in the pathogenesis of different cancer types affecting the gastrointestinal tract system. We also scrutinize the evidence regarding the role of microbiota in anticancer drug responses. Further, we discuss the use of probiotics, fecal microbiota transplantation, and antibiotics, either alone or in combination with anticancer drugs for prevention and treatment of gastrointestinal tract cancers.

Isolated spontaneous biceps abscess causing septic shock in a diabetic patient: A rare case report

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Intramuscular abscesses, particularly in the biceps brachii, are very rare.

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The majority are associated with haematoma secondary to trauma, intramuscular injections, or systemic disease.

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If untreated, it can rapidly lead to septic shock and involvement of surrounding joints.

Introduction

Intramuscular abscesses, particularly in the biceps brachii, are an extremely rare phenomenon. When present they are usually secondary to trauma, intramuscular injections, or systemic disease.

Presentation of case

A 56 year old diabetic woman presented to our emergency department with a 3 day history of fever, cough, and a painful left shoulder. Although she had a mechanical fall 2 weeks prior, she denied any pain in her shoulder immediately after the fall. She also denied any history of drug abuse or recent intramuscular injection. On examination she looked acutely unwell and was in acute septic shock requiring inotropic support. Computed tomography of her shoulder showed a large intramuscular abscess in her left biceps brachii muscle. She was immediately taken to the operating theatre for open exploration and washout of the abscess. The multiloculated abscess was tracking into the glenohumeral joint. Post operatively she showed significant clinical improvement and after a 2 week course of intravenous antibiotics recovered well and was discharged from hospital.

Discussion

Intramuscular abscesses are usually seen in patients who are immunocompromised. Intramuscular needle injections and haematomas secondary to trauma are also risk factors. To the best of our knowledge, there have only been 4 published reports in the English literature of intramuscular abscess formation in the biceps brachii.

Conclusion

We report a case of a seemingly spontaneous intramuscular biceps abscess in a diabetic patient presenting with septic shock.

Novel association of Streptococcus gallolyticus subspecies pasteurianus and hepatocelluar carcinoma: opening new frontiers

BACKGROUND

Streptococcus gallolyticus subsp. gallolyticus bacteremia is associated with colorectal malignancies. There is limited data regarding the association of Streptococcus gallolyticus subsp. pasteurianus with malignancies. We aimed to study the pattern of isolation of Streptococcus gallolyticus and analysis of risk factors in patients with hepatobiliary diseases. We also planned to evaluate its association with hepatocellular malignancy.

METHODS

We analyzed clinical and laboratory data of 68 cases of Streptococcus gallolyticus infections (77 isolates) from January 2013 to December 2017. These included blood (58), ascitic fluid (15), bile (2) and pleural fluid (2). We analyzed the risk factors in patients developing malignancy with Streptococcus gallolyticus infections.

RESULTS

Amongst the 68 patients studied, eight (11.76%) had confirmed malignancies, hepatocellular carcinoma (HCC) (5), rectal adenocarcinoma (1), pancreatic carcinoma (1) and uterine tumors (1). Simultaneous isolation of S. gallolyticus subsp. pasteurianus from blood and ascitic fluid in eight patients (11.8%, p = .01) was significantly associated with the occurrence of HCC. Streptococcus gallolyticus infection with HCC was associated with younger age (median 55 years), lymphocytosis and elevated gamma-glutamyl transferase (GGT).

CONCLUSIONS

This study provides a novel insight into the association of Streptococcus gallolyticus subspecies pasteurianus with HCC. The isolation of the organism from blood and ascitic fluid should prompt the clinicians to search for evidence of HCC actively.

Clinically Occult Rectal Carcinoma Identified in a Case of Streptococcus bovis Endocarditis on Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Case Report and Review of Literature

Numerous studies over past four decades have implicated a strong association of Streptoccus bovis infection with colorectal carcinomas. Strong is this association that a screening colonoscopy for identifying malignancy is considered mandatory in patients whose blood/fecal cultures show growth of this particular pathogen. Here, we report an interesting case of a 61-year-old female patient who presented with pyrexia of unknown origin for 3 weeks. Positron emission tomography/computed tomography, in addition to helping diagnose mitral valve endocarditis, also identified a clinically occult T2N0 rectal carcinoma.

A Rare Case of Streptococcus alactolyticus Infective Endocarditis Complicated by Septic Emboli and Mycotic Left Middle Cerebral Artery Aneurysm

To date, S. alactolyticus endocarditis complicated by middle cerebral artery aneurysm has not been reported. We describe the case of a 65-year-old female with a history of hypertrophic cardiomyopathy with left ventricular outflow tract obstruction presenting with confusion and a apical holosystolic murmur. Angiography of the brain identified new bilobed left middle cerebral artery aneurysm. Serial blood cultures grew S. alactolyticus, and aortic and mitral valve vegetation were discovered on transesophageal echocardiography. The patient was treated with antimicrobial therapy, mitral and aortic valve replacements, and microsurgical clipping of cerebral aneurysm. This case serves to highlight the pathogenicity of a sparsely described bacterium belonging to the heterogenous S. bovis complex.

Streptococcus bovis endocarditis: Update from a multicenter registry

BACKGROUND

Infective endocarditis (IE) due to Streptococcus bovis has been classically associated with elderly patients, frequently involving >1 valve, with large vegetations and high embolic risk, which make it a high-risk group. Our aim is to analyze the current clinical profile and prognosis of S bovis IE episodes, in comparison to those episodes caused by viridans group streptococci and enterococci.

METHODS

We analyzed 1242 consecutive episodes of IE prospectively recruited on an ongoing multipurpose database, of which 294 were streptococcal left-sided IE and comprised our study group. They were classified into 3 groups: group I (n = 47), episodes of IE due to S bovis; group II (n = 134), episodes due to viridans group streptococci; and group III (n = 113), those episodes due to enterococci.

RESULTS

The incidence of enterococci IE has significantly increased in the last 2 decades (6.4% [1996-2004] vs 11.1% [2005-2013]; P = .005), whereas the incidence of IE due to S bovis and viridans streptococci have remained stable (4% and 10%, respectively). Gender distribution was similar in the 3 groups. Patients with S bovis and enterococci IE were older than those from group II. Nosocomial acquisition was more frequent in group III. Concerning comorbidity, diabetes mellitus (36.7% vs 9.2% vs 26.8%; P < .001) was more common in groups I and III. Chronic renal failure was more prevalent in patients from group III (4.2% vs 1.5% vs 19%; P < .001). Prosthetic valve IE was more frequent in enterococcal IE. Infection upon normal native valves was more frequent in S bovis IE. Colorectal tumors were found in 69% of patients from this group. Vegetation detection was similar in the 3 groups. However, vegetation size was smaller in S bovis IE. During hospitalization, in-hospital complications and in-hospital mortality were higher in enterococci episodes.

CONCLUSIONS

S bovis IE accounts for 3.8% of all IE episodes in our cohort; it is associated with a high prevalence of colonic tumors, with predominance of benign lesions, and affects patients without preexisting valve disease. It is related to small vegetations and a low rate of in-hospital complications, including systemic embolisms. In-hospital mortality is similar to that of viridans group streptococci.

Streptococcus gallolyticus bacteraemia in hepatobiliary-pancreatic and colonic pathologies

BACKGROUND

Streptococcus gallolyticus bacteraemia has been associated with several pathologies, including bacterial endocarditis and colorectal cancer.

AIMS

In this study, we have analysed whether Streptococcus gallolyticus bacteraemia is associated with an increased risk of hepatobiliary and colonic pathology. The association with other pathologies and the antibiotic sensitivities of Streptococcus gallolyticus were also analysed.

DESIGN

Observational retrospective study.

METHODS

The case notes of patients with documented Streptococcus gallolyticus bacteraemia between 2007 and 2012 at Mater Dei hospital (Malta) were reviewed. Demographic and clinical data, including co-morbidities, clinical investigations, antibiotic sensitivities and mortality were analysed.

RESULTS

A total of 42 patients (33 males, 9 females) were recruited. Two patients were pre-term infants and were therefore excluded from the study. Mean age of the cohort population studied was 72 years (SD ± 14). One-year survival rate was 62%. Gastrointestinal (colonic and hepatobiliary-pancreatic) pathologies were present in 59.5% of patients with 16% of this group having more than one gastrointestinal pathology. High incidence rates of underlying diabetes mellitus (28.6%), valvular heart disease (21.4%) and malignancies (21.4%) were noted in this study. Furthermore, we observed that 14.3% of patients had an underlying respiratory pathology. Streptococcus gallolyticus was 100% sensitive to cefotaxime and vancomycin but was highly resistant to clindamycin, erythromycin and tetracycline.

CONCLUSION

Streptococcus gallolyticus bacteraemia is commoner in the elderly and in those with multiple underlying co-morbidities. The high incidence of gastrointestinal pathologies among patients with Streptococcus gallolyticus bacteraemia (59.5%) suggests that a thorough work-up for colonic and hepatobiliary/pancreatic pathology should be carried out in these patients.

A case-control study: are urological procedures risk factors for the development of infective endocarditis?

OBJECTIVE

To evaluate the association between urological procedures and the development of infective endocarditis (IE), as there are case-reports linking urological procedures to IE but evidence of a causal relationship is lacking and no major guidelines advise prophylaxis to prevent development of IE during transurethral urological procedures. No case-control study has been undertaken to examine the relationship between urological procedures and the development of IE.

PATIENTS AND METHODS

Retrospective evaluation of the IE database at our institution. The population consisted of patients diagnosed with enterococcal, staphylococcal, Streptococcus bovis-group and oral streptococcal IE over a 10-year period. Possible risk factors for the development of IE, including urological procedures were collected. A case-control design was used and univariable and multivariable analyses were carried out. Missing data was accounted for using the multiple imputations method.

RESULTS

We included 384 patients with IE. There was a statistical association between the development of enterococcal IE and preceding urological procedures (odds ratio 8.21, 95% confidence interval 3.54-19.05, P < 0.05). Increasing age and being an intravenous drug user were also associated with enterococcal IE. Haemodialysis and the presence of an intracardiac device were associated with the development of coagulase-negative staphyloccal IE.

CONCLUSION

This is the first study to show a statistical association between urological procedures and the development of IE. The bacteraemia leading to IE may be a result of the urological procedures or a consequence of the underlying urological pathology causing recurrent subclinical bacteraemias.

Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study

BACKGROUND

The association between bacteremia by Streptococcus gallolyticus subsp. gallolyticus (SGG) and colorectal neoplasia (CRN) is well established but the frequency of the association varies widely in different studies. We conducted a case-control study to assess the association between SGG bacteremia and CRN.

METHODS

An analysis of all SGG bacteremias was performed during the period 1988-2011. The frequency of CRN in patients with SGG bacteremia was compared with the frequency of CRN in a symptomatic control group of patients matched at a 1:2 ratio for gender and age (±3 years) without S. bovis bacteremia and personal history of CRN and with increased risk of CRN (by the presence of symptoms, signs, or test suspicious of colonic pathology or by family history of CRN).

RESULTS

One hundred nine cases of SGG bacteremia were detected (mean age, 66 years; 87% male). Colonoscopy was performed in 98 cases, diagnosing 69 cases of CRN: 57 adenomas (39 advanced adenomas) and 12 invasive carcinomas. Only 4 cases had suspected CRN before the blood culture. The prevalence of CRN was higher in patients with SGG bacteremia than in the 196 control patients (70% vs 32%; odds ratio [OR], 5.1; 95% confidence interval [CI], 3.0-8.6). This difference was not significant when comparing nonadvanced adenomas (19% vs 12%), but we found significant differences in advanced adenomas (40% vs 16%; OR, 3.5; 95% CI, 2.0-6.1) and invasive carcinomas (12% vs 5%; OR, 2.9; 95% CI, 1.2-6.9).

CONCLUSIONS

The frequency of CRN among SGG infected patients is significantly increased compared with symptomatic age-matched controls, indicating that SGG infection is a strong indicator for underlying occult malignancy.

Streptococcus bovis peritonitis complicating peritoneal dialysis--a review of 10 years' experience

OBJECTIVE

An association of Streptococcus bovis bacteremia with carcinoma of colon has been reported, but data regarding peritoneal dialysis (PD) peritonitis caused by S. bovis is scarce. In this study, we examined the clinical characteristics, associations, and outcomes of this disease entity.

METHODS

The case records of patients with S. bovis PD peritonitis presenting to 2 renal centers between January 2000 and September 2010 were reviewed. Clinical features and outcomes were identified and analyzed.

RESULTS

Of cultures from 23 episodes of S. bovis peritonitis in 20 patients (1.28% of all peritonitis episodes at our center), 19 (82.6%) showed S. bovis alone, and 4 (17.4%) showed mixed growth. In 7 episodes, the S. bovis was moderately resistant to penicillin G. Rates of resistance to clindamycin and erythromycin were 43.5% and 47.8% respectively. In 18 episodes (78.3%), a primary response was achieved with a first-generation cephalosporin and an aminoglycoside. In 4 episodes, a secondary response was achieved after a switch from cephalosporin to vancomycin, and in 1 episode with mixed growth, the Tenckhoff catheter had to be removed. Repeat peritonitis occurred in 3 patients at a mean of 50.0 months (range: 24.2 - 83.1 months). Of the 20 patients of S. bovis peritonitis, 10 (50%) underwent either a barium enema or a colonoscopy. One patient had history of colonic carcinoma 2 years before the peritonitis, and a subsequent work-up revealed no recurrence. Three patients had diverticulosis, and one had a concomitant sigmoid polyp. Findings in the other 6 patients were normal. No colorectal malignancy had developed in the remaining 10 patients after a mean follow-up of 76.6 months (range: 0.8 - 125.1 months).

CONCLUSIONS

Outcomes in S. bovis PD peritonitis were favorable, and an association with colorectal cancer was not found in our patients. Routine colonoscopy in these patients remains controversial and should be individualized.

Streptococcus bovis meningitis and hemorrhoids

We report a case of Streptococcus bovis (Streptococcus gallolyticus subsp. pasteurianus) meningitis, a rare cause of central nervous system (CNS) infection in an adult, and comment on the importance of investigation of the lower gastrointestinal tract to identify a portal of entry in cases of systemic Streptococcus bovis infection.

Interactions between endocarditis-derived Streptococcus gallolyticus subsp. gallolyticus isolates and human endothelial cells

Background

Streptococcus gallolyticus subsp. gallolyticus is an important causative agent of infective endocarditis (IE) but the knowledge on virulence factors is limited and the pathogenesis of the infection is poorly understood. In the present study, we established an experimental in vitro IE cell culture model using EA.hy926 and HUVEC cells to investigate the adhesion and invasion characteristics of 23 Streptococcus gallolyticus subsp. gallolyticus strains from different origins (human IE-derived isolates, other human clinical isolates, animal isolates). Adhesion to eight components of the extracellular matrix (ECM) and the ability to form biofilms in vitro was examined in order to reveal features of S. gallolyticus subsp. gallolyticus endothelial infection. In addition, the strains were analyzed for the presence of the three virulence factors gtf, pilB, and fimB by PCR.

Results

The adherence to and invasion characteristics of the examined S. gallolyticus subsp. gallolyticus strains to the endothelial cell line EA.hy926 differ significantly among themselves. In contrast, the usage of three different in vitro models (EA.hy926 cells, primary endothelial cells (HUVECs), mechanical stretched cells) revealed no differences regarding the adherence to and invasion characteristics of different strains. Adherence to the ECM proteins collagen I, II and IV revealed the highest values, followed by fibrinogen, tenascin and laminin. Moreover, a strong correlation was observed in binding to these proteins by the analyzed strains. All strains show the capability to adhere to polystyrole surfaces and form biofilms. We further confirmed the presence of the genes of two known virulence factors (fimB: all strains, gtf: 19 of 23 strains) and demonstrated the presence of the gene of one new putative virulence factor (pilB: 9 of 23 strains) by PCR.

Conclusion

Our study provides the first description of S. gallolyticus subsp. gallolyticus adhesion and invasion of human endothelial cells, revealing important initial information of strain variability, behaviour and characteristics of this as yet barely analyzed pathogen.

Aortic and tricuspid endocarditis due to Streptococcus gallolyticus in an immunocompetent patient with a normal heart

Endocarditis due to Streptococcus gallolyticus, an agent previously included in the Streptococcus bovis denomination is a serious disease, often associated with lesions of the colon mucosa. Aortic valve is more often affected and tricuspid involvement is quite rare. We present a case of a 56-year-old man who was admitted with a 2-month history of fever. Echocardiogram revealed vegetations on the aortic and tricuspid valve and blood cultures grew S. gallolyticus. Thoracic X-ray and computed tomography were consistent with septic pulmonary embolism. Despite optimal antibiotic therapy he developed an ischemic stroke and acute aortic regurgitation, which led to emergent surgery. Colonoscopy found a benign adenoma which was excised, and the patient had a full recovery.

[Comparative analysis of antibiotic sensitivity of Streptococcus pneumoniae strains isolated from patients and carriers]

The data on antibiotic sensitivity of 38 strains of S. pneumoniae isolated from children and 46 strains isolated from carriers are presented. The isolates from the carriers had significantly higher sensitivity to benzylpenicillin, ampicillin, methicillin, oxacillin, cefazolin, erythromycin, oleandomycin and lincomycin. Resistance to gentamicin was more frequent in the strains isolated from the carriers. Among the strains of S. pneumoniae isolated from the patients and carriers representatives of serovar K19 were more frequent. There were no statistically reliable difference in them by sensitivity to benzylpenicillin, ampicillin, cefazolin, lincomycin and rifampicin. Still, the isolates from the carriers were much more sensitive to methicillin, oxacillin, oleandomycin and erythromycin.