Kyle Hill, na
Doctor
St. Joseph's Medical Center, United States
Disclosure information not submitted.
Josebelo Chong, na
Doctor
St. Joseph's Medical Center, United States
Disclosure information not submitted.
Title: A Rare Case of Infective Endocarditis Caused by Streptococcus pyogenes Bacteremia
Case Report Body:
Introduction: Streptococcus pyogenes is a gram-positive, catalase-negative, facultative anaerobic, group A β-hemolytic streptococcus bacterium. With a prevalence of 1.9%, Streptococcus pyogenes is a rare cause of endocarditis. It has been shown that Streptococcus pyogenes strains with higher representation of fibronectin and fibrinogen-binding genes are more associated with endocarditis than isolates found in soft tissue and respiratory tract infections. Due to significant complications associated with infective endocarditis, prompt diagnosis and treatment is imperative.
Description: A 57 year-old male with past medical history of intravenous methamphetamine abuse, chronic obstructive pulmonary disease, chronic left lower extremity wound, and liver cirrhosis, was brought in by ambulance due to altered mental status and right lower extremity cellulitis. Glasgow Coma Scale on presentation was 11. Initial vital signs showed a temperature of 39.8 degrees Celsius, sinus tachycardia at 115 beats per minute, blood pressure of 96/40, respiratory rate of 25, and pulse oximetry of 100% on room air. Lab work demonstrated a lactic acid of 3.3 mmol/L, troponin 3.4 ng/mL, and a C-reactive protein of 14 mg/dL. Right lower extremity cellulitis imaging studies were unremarkable for soft tissue emphysema or abscess. Head imagining was unremarkable. He was treated with Vancomycin and Ceftriaxone. Blood cultures were positive for Streptococcus pyogenes. Antibiotics were switched to Clindamycin and Ceftriaxone. His mental status deteriorated to the point of becoming obtunded requiring endotracheal intubation. A transesophageal echocardiogram revealed a 0.7 centimeter (cm) aortic valve vegetation with a 0.7 cm free-mobile string like structure attached to the right coronary cusp. There was also a 1.7 cm similar appearing structure attached to the non-coronary cusp. Due to his prognosis his family decided that comfort care would be the best option. He expired shortly after.
Discussion: The presentation of Streptococcus pyogenes bacteremia triggered further examination to reveal a rare case of acute endocarditis. While endocarditis caused by group A streptococci is uncommon, clinicians should maintain a high index of suspicion when encountering group A streptococci bacteremia with risk factors such as intravenous drug use.