Chest Infections: Student/Resident Case Report Poster - Chest Infections II |

Lung Abscess With Metastatic Brain Abscesses (MBA) Due to Steptococcus Anginosus (SA) in an Immunocompetent Patient: A Rare Case Report FREE TO VIEW

Ahad Ayaz, MD; Chintan Desai, MD; Siddique Chaudhary, MD; John Youssef, MD; Susan Smith, MD
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McLaren Regional Medical Center, Flint, MI

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):187A. doi:10.1016/j.chest.2016.08.196
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SESSION TITLE: Student/Resident Case Report Poster - Chest Infections II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Streptococcus anginosus group (SAG) is normal flora of the GI and GU tracts. While other species are notorious for brain and abdominal abscesses, SA has rarely been implicated. Our patient had simultaneous lung and MBA due to SA.

CASE PRESENTATION: A 53-year old male with COPD and recurrent pneumonia presented with headache, productive cough, dyspnea and fever. He had failed outpatient clarithromycin for right upper lobe pneumonia 2 weeks previously. On arrival vitals were stable. Exam showed diminished breath sounds on the right. Neuro exam was normal. CBC showed neutrophilia. Other labs were normal. CXR showed a new right pulmonary nodule while CT revealed a right lower lobe mass with central necrosis worrisome for malignancy. Brain MRI showed multiple, small, ring-enhancing supratentorial lesions with surrounding edema. Otherwise metastatic workup was negative. CT-guided core lung biopsy showed chronic inflammation and focal abscess. Tissue cultures were positive for alpha-hemolytic strep, but negative for TB or fungus. Blood cultures were negative. Differential included Streptococcus and Nocardia. Due to penicillin allergy, he was prescribed six weeks of outpatient IV meropenam monotherapy. Patient returned in two weeks with complaints of sudden onset confusion and complex partial upper extremity seizures. Physical exam including vitals and neuro exam was normal as was CBC and BMP. Repeat MRI revealed ring-enhancing lesions, increasing in size. Antibodies for cysticercosis, toxoplasmosis, Cryptococcus and HIV were negative. CNS lesions were biopsied. Histopathology confirmed an abscess with surrounding reactive glial tissue. Tissue and blood cultures were now positive for SA. Echocardiogram was negative for vegetations. Immunoglobulin levels were normal. He underwent desensitization and was treated with IV ceftriaxone and oral metronidazole for 6 weeks.

DISCUSSION: Although opportunistic, these organisms have the potential to cause invasive infections even in immunocompetent patients. We found only one similar case in the literature. Virulence factors include a polysaccharide capsule hindering phagocytosis; production of hydrolytic enzymes altering the basement membrane; and binding to the platelet-fibrin-complex, leading to a prothrombotic state. They are sensitive to penicillins and cephalosporins but not macrolides and carbapenams.

CONCLUSIONS: A broad differential diagnosis with prompt recognition and treatment is essential to prevent disseminated infection and sepsis

Reference #1: Al-Saffar F, Torres-Miranda D, Ibrahim S, Shujaat A. How an Opportunistic Infection Can Mess with Your Brain and Take Your Breath Away: A Rare Case of Simultaneous Lung and Brain Abscess due to Streptococcus anginosus. Case Rep Infect Dis 2015; 2015:462459.

Reference #2: Asam D, Spellerberg B. Molecular pathogenicity of Streptococcus anginosus. Mol Oral Microbiol. 2014;29(4):145-155.

DISCLOSURE: The following authors have nothing to disclose: Ahad Ayaz, Chintan Desai, Siddique Chaudhary, John Youssef, Susan Smith

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