WHEN GOOD BACTERIA GO WRONG

POSTER PRESENTATIONS

Introduction. First case of iatrogenically caused endocarditis due to lactobacillus and strep bovis in the literature. Case presentation. 52 year old HIV- positive male (CD4 count 440) with a PMH of poly-substance abuse, DM type 2, and CKD lll who presented with sharp, nonradiating 10/10 back pain for one day. He had associated progressive shortness of breath with cough and diaphoresis. Vitals on initial presentation were 101.8F, 122 bpm, 23 breaths/min, and 118/69 mmHg. On physical exam he was ill appearing, tachycardic and diaphoretic with coarse breath sounds and rhonchi in the right lower lobe. CBC was pertinent for leukocytosis of 22k with 77% neutrophils and a bandemia of 5%. Pan cultures were negative. CT of the chest, abdomen and pelvis revealed a multiloculated right pleural effusion (without any parenchymal lung disease) with collection that seemed to be in connection with the mediastinum. The patient was empirically started on Vancomycin 1g IV BID and Ceftriaxone 1g IV QD. A diagnostic thoracentesis was performed and a right pigtail catheter was placed which 67 drained minimal clear serous fluid. A 2D Echo was performed for the persistent tachycardia and demonstrated anterior MV leaflet mobile echodensity/vegetation with an EF of 65-70%. Deviation From the Expected. The patient’s history of recent retching and NBNB emesis with associated back pain led to a suspicion of an esophageal tear with subsequent leakage into the pleura which was confirmed when an esophagram revealed a mediastinal abscess with connection to the esophagus. The patient then had an emergent thoracotomy with decortication and drainage of the abscess. Wound cultures from the abscess grew Group D Strep/Lactobacillus and the patient was initially started on Unasyn 3g IV Q6/Flagyl 500mg PO Q8 which was then modified to a 4 week course including 2 weeks of unasyn and flagyl followed by 2 weeks of oral augmentin and flagyl to cover for his endocarditis. Discussion. Our case is a relatively typical presentation of a rare cause of endocarditis. Unlike the typical causes of endocarditis, the most common being Staph aureus, Viridans group strep, Enterococcus, or HACEK species, Lactobacillus and Strep Bovis are uncommon etiologies for acute endocarditis. In the literature Strep bovis is not as uncommon as lactobacillus however without colon cancer or recent gastrointestinal surgery there are very few discussed cases. We are attributing the seeding of the heart valve with these rare etiologies to the yogurt that he was served early in his hospital stay. It is assumed that due to his pre-existing esophageal tear a direct rout to the mediastinum as well as to the bloodstream was present allowing a transient bacteremia which likely seeded the valve. If this is the case this would have been the first iatrogenically caused endocarditis due to lactobacillus and strep bovis in the literature. Conclusion. Esophageal perforation is a deadly injury if not treated in a timely manner. Grants. None