Unusual association of diseases/symptoms
CASE REPORT
Streptococcus viridians bacteraemia and colonic adenocarcinoma Avenir Mulita, Tokunbo Ajayi Department of Internal Medicine, North Shore Medical Center, Salem, Massachusetts, USA Correspondence to Dr Avenir Mulita, [email protected] Accepted 8 May 2014
SUMMARY Even though Streptococcus bacteraemia is an infrequent presentation of colonic malignancies, there is a well-established link between Streptococcus bovis bacteraemia and colonic malignancies. Most of the physicians are well aware of this correlation and further workup is pursued in most of the cases. However, many physicians may not be aware that other species of Streptococcus viridians, other than S. bovis, can be associated with colonic malignancies. In this case report, we present a case of Streptococcus viridians (anginosus) bacteraemia as a complication of an undiagnosed sigmoid adenocarcinoma. While further evidence is needed to warrant a gastrointestinal (GI) workup in a patient with other species of Streptococcus viridians bacteraemia, we would like to increase the awareness in the physicians’ community regarding Streptococcus viridians, other than S. bovis bacteraemia. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm.
BACKGROUND Over the years, there has been growing evidence supporting the relationship between Streptococcus bovis and colonic malignancies.1 2 The scope of the evidence is also expanding in the association with other gastrointestinal neoplasms and liver disease.3 4 Getting a colonoscopy after a S. bovis bacteraemia is the standard of care at this point.
To cite: Mulita A, Ajayi T. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-203695
Figure 1
The focus of this case report will be on other species of Streptococcus viridians. With the exception of sporadic case reports published in different journals, including some literature review, a direct correlation is not yet well established between Streptococcus viridians, other than S. bovis and colonic malignancies. Although there might be a link between the two entities, since a proved correlation is not yet established, many doctors are not aware of this possibility.
CASE PRESENTATION The patient is a 73-year-old man with a medical history of hypertension, hyperlipidaemia and recently diagnosed atrial fibrillation (on warfarin), who presented with recurrent gastrointestinal bleed. The patient was discharged from hospital 1 week ago. At the previous admission, he was hospitalised for Streptococcus viridians (anginosus) bacteraemia, anaemia, gastrointestinal bleeding and new onset atrial fibrillation. During that presentation, the patient had a temperature of 103.7 degree Fahrenheit, heart rate 135 beats per minute, blood pressure 135/72 mm/Hg, respiratory rate 20 breaths per minute and oxygen saturation 94% on room air. The patient was pale and tachycardic. The abdomen was non-tender, but mildly distended. There was no hepatosplenomegaly and no palpable mass. Rectal examination revealed no mass, but it was guaiac positive. Haemoglobin and haematocrit were 8 and 24.9, respectively, and leucocytes were 10 000 with
Apple core lesion at the sigmoid colon.
Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
1
Unusual association of diseases/symptoms
Figure 3
Figure 2 Apple core lesion at the sigmoid colon. 78% neutrophils and 16% bands. Urinalysis and chest X-ray were negative. CT of the abdomen and pelvis showed nonspecific focal thickening of sigmoid colon, likely in the setting of infectious/inflammatory entities, based on radiology report. No abscess or fluid collection noted. At that time, Streptococcus viridians (anginosus) sensitive to penicillin grew in the blood cultures. Transthoracic and transoesophageal echocardiography showed no vegetation. Even though the patient had bacteraemia with a microorganism known to cause infective endocarditis, he did not meet Duke criteria to make that diagnosis. Surveillance blood cultures also came out negative. No clear source of bacteraemia was found at that time, but given the findings on abdominal CT and poor dentition, it would most likely be in the intestine or oral cavity. Regarding anaemia and gastrointestinal bleeding, the patient had oesophagogastroduodenoscopy that showed gastric ulcers, for which the patient received proton pump inhibitor. Immunostaining for Helicobacter pylori was negative and biopsy was negative for malignant cells. Regarding atrial fibrillation, the patient was started on warfarin. The patient was discharged on treatment with penicillin and was instructed to follow-up with the gastroenterologist (colonoscopy) and dental workup. The patient was readmitted for gastrointestinal bleeding 1 week after discharge. On the second admission the patient’s blood pressure was 119/65 mm/Hg, heart rate 81 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation of 96% on room air with a temperature of 99.2 degree Fahrenheit. The physical examination revealed mild pallor. The abdomen was soft non-tender, mildly distended and with hyperactive bowel sounds. No rebound, guarding or rigidity was noted. Digital rectal examination was grossly bloody. His laboratory data showed that haemoglobin and haematocrit were 8.5 and 26.1, respectively, and no leukocytosis or left shift. Oesophagogastro-duodenoscopy on the previous admission showed healing gastric ulcers, but no active bleeding. Since the digital rectal examination showed bright red blood, colonoscopy was pursued. The patient developed obstruction during the preparation. CT of the abdomen showed possible colonic pneumatosis and colonoscopy was abandoned at that time. Barium enema showed apple core lesion, suspicious of neoplasm 2
Mass at the level of the sigmoid colon.
at the level of distal sigmoid (figures 1 and 2). Endoscopy showed an obstructing mass at the level of sigmoid colon (figures 3 and 4). A stent was placed through the mass to relieve the obstruction. No samples were taken during the sigmoidoscopy, but macroscopic appearance was consistent with malignant lesion. Tumour markers showed a carcinoembryonic antigen level of 31.3. The patient was taken to the operating room and had a sigmoid colectomy with a descending end colostomy. Surgical pathology/cytology report showed invasive colonic adenocarcinoma. After the discharge, he has been followed by a haematology– oncology specialist for stage II T3 N0 colon cancer. He is feeling better and gaining weight.
DISCUSSION Since the first article in 19511 that suggested a correlation between S. bovis and colonic neoplasm, there has been growing evidence that established this correlation, identified both on clinical2–4 and laboratory studies.5–7 While for S. bovis there is enough evidence to pursue further workup, in a case of bacteraemia there is not yet a direct link between other species of Streptococcus viridians bacteraemia and colonic neoplasm with the exception of sporadic case reports like this one. Streptococcus viridians is a group of α-haemolytic or non-haemolytic streptococci found mostly in the oral cavity and gastrointestinal (GI) tract. S. bovis is part of this group as well. Streptococcus viridians usually have low virulence and would not cause sepsis unless there is some impaired immunity on the background and there is damage of the integrity of mucosa. In the case above the Streptococcus viridians (anginosus) bacteraemia seems to be an early signs of colonic neoplasm. As mentioned previously, there have been case reports that hint
Figure 4
Mass at the level of the sigmoid colon. Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
Unusual association of diseases/symptoms towards a correlation between species of Streptococcus viridians other than bovis, with colonic neoplasms.8–15 Even with these case reports, there has not been enough evidence to include a routine workup for colonic neoplasm in a patient with Streptococcus viridians bacteraemia, other than S. bovis, for which there is a well-established link. Furthermore, there are no definite studies to evaluate if proteins related with other species of Streptococcus viridians have any effect on carcinogenesis or angiogenesis. While further evidence is needed to warrant a GI workup in a patient with Streptococcus viridians bacteraemia other than bovis, we would like to increase the awareness in the physicians’ community regarding unexplained bacteraemia due to other species of Streptococcus viridians. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm. In the case above, the patient had Streptococcus anginosus bacteraemia, which despite being part of Streptococcus viridians group, is mostly associated with abscess formation, rather than infective endocarditis.
Contributors AM identified and managed the patient, wrote the manuscript and conducted the literature review. TA was mostly involved in the literature review and the final presentation. AM and TA are the guarantors. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
5
6
Learning points ▸ In the case of unexplained bacteraemia thorough workup is needed to identify the source. ▸ Physicians need to be aware that Streptococcus viridians, other than Streptococcus bovis, bacteraemia can be an early sign of colonic neoplasm. ▸ Gastrointestinal workup may be warrantied in certain cases of Streptococcus viridians bacteraemia, other than bovis, as it can reveal colonic neoplasm. ▸ Identification of microorganism at the level of species it is very helpful, since it gives you clues towards the complications and associations. ▸ In case of iron deficiency anaemia both upper and lower endoscopy should be performed, even in the case when upper endoscopy has revealed a source, since other sources can be missed.
7
8
9
10 11 12 13 14 15
McCOY WC, Mason JM III. Enterococcal endocarditis associated with carcinoma of the sigmoid; report of a case. J Med Assoc State Ala 1951;21:162–6. Corredoira-Sánchez J, García-Garrote F, Rabuñal R, et al. Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study. Clin Infect Dis 2012;55:491–6. Gold JS, Bayar S, Salem RR. Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy. Arch Surg 2004;139:760–5. Alazmi W, Bustamante M, O’Loughlin C, et al. The association of Streptococcus bovis bacteremia and gastrointestinal diseases: a retrospective analysis. Dig Dis Sci 2006;51:732–6. Biarc J, Nguyen IS, Pini A, et al. Carcinogenic properties of proteins with pro-inflammatory activity from Streptococcus infantarius (formerly S. bovis). Carcinogenesis 2004;25:1477–84. Ellmerich S, Schöller M, Duranton B, et al. Promotion of intestinal carcinogenesis by Streptococcus bovis. Carcinogenesis 2000;21:753–6. Burnett-Hartman AN, Newcomb PA, Potter JD. Infectious agents and colorectal cancer: a review of Helicobacter pylori, Streptococcus bovis, JC virus, and human papillomavirus. Cancer Epidemiol Biomarkers Prev 2008;17:2970–9. Lin CY, Chao PC, Hong GJ, et al. Infective endocarditis from Streptococcus viridans associated with colonic carcinoma: a case report. J Card Surg 2008;23:263–5. Tzur T, Liberman S, Felzenstein I, et al. Liver abscesses caused by Streptococcus milleri: an uncommon presenting sign of silent colonic cancer. Isr Med Assoc J 2003;5:206–7. Marinella MA. Streptococcus sanguis bacteremia associated with cecal carcinoma: case report and review of the literature. Am J Gastroenterol 1997;92:1541–2. Siegert CE, Overbosch D. Carcinoma of the colon presenting as Streptococcus sanguis bacteremia. Am J Gastroenterol 1995;90:1528–9. Macaluso A, Simmang C, Anthony T. Streptococcus sanguis bacteremia and colorectal cancer. South Med J 1998;91:206–7. Fass R, Alim A, Kaunitz JD. Adenocarcinoma of the colon presenting as Streptococcus sanguis bacteremia. Am J Gastroenterol 1995;90:1343–5. Kampe CE, Vovan T, Alim A, et al. Streptococcus sanguis bacteremia and colorectal cancer: a case report. Med Pediatr Oncol 1995;24:67–8. Legier JF. Streptococcus salivarius meningitis and colonic carcinoma. South Med J 1991;84:1058–9.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
3
CASE REPORT
Streptococcus viridians bacteraemia and colonic adenocarcinoma Avenir Mulita, Tokunbo Ajayi Department of Internal Medicine, North Shore Medical Center, Salem, Massachusetts, USA Correspondence to Dr Avenir Mulita, [email protected] Accepted 8 May 2014
SUMMARY Even though Streptococcus bacteraemia is an infrequent presentation of colonic malignancies, there is a well-established link between Streptococcus bovis bacteraemia and colonic malignancies. Most of the physicians are well aware of this correlation and further workup is pursued in most of the cases. However, many physicians may not be aware that other species of Streptococcus viridians, other than S. bovis, can be associated with colonic malignancies. In this case report, we present a case of Streptococcus viridians (anginosus) bacteraemia as a complication of an undiagnosed sigmoid adenocarcinoma. While further evidence is needed to warrant a gastrointestinal (GI) workup in a patient with other species of Streptococcus viridians bacteraemia, we would like to increase the awareness in the physicians’ community regarding Streptococcus viridians, other than S. bovis bacteraemia. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm.
BACKGROUND Over the years, there has been growing evidence supporting the relationship between Streptococcus bovis and colonic malignancies.1 2 The scope of the evidence is also expanding in the association with other gastrointestinal neoplasms and liver disease.3 4 Getting a colonoscopy after a S. bovis bacteraemia is the standard of care at this point.
To cite: Mulita A, Ajayi T. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-203695
Figure 1
The focus of this case report will be on other species of Streptococcus viridians. With the exception of sporadic case reports published in different journals, including some literature review, a direct correlation is not yet well established between Streptococcus viridians, other than S. bovis and colonic malignancies. Although there might be a link between the two entities, since a proved correlation is not yet established, many doctors are not aware of this possibility.
CASE PRESENTATION The patient is a 73-year-old man with a medical history of hypertension, hyperlipidaemia and recently diagnosed atrial fibrillation (on warfarin), who presented with recurrent gastrointestinal bleed. The patient was discharged from hospital 1 week ago. At the previous admission, he was hospitalised for Streptococcus viridians (anginosus) bacteraemia, anaemia, gastrointestinal bleeding and new onset atrial fibrillation. During that presentation, the patient had a temperature of 103.7 degree Fahrenheit, heart rate 135 beats per minute, blood pressure 135/72 mm/Hg, respiratory rate 20 breaths per minute and oxygen saturation 94% on room air. The patient was pale and tachycardic. The abdomen was non-tender, but mildly distended. There was no hepatosplenomegaly and no palpable mass. Rectal examination revealed no mass, but it was guaiac positive. Haemoglobin and haematocrit were 8 and 24.9, respectively, and leucocytes were 10 000 with
Apple core lesion at the sigmoid colon.
Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
1
Unusual association of diseases/symptoms
Figure 3
Figure 2 Apple core lesion at the sigmoid colon. 78% neutrophils and 16% bands. Urinalysis and chest X-ray were negative. CT of the abdomen and pelvis showed nonspecific focal thickening of sigmoid colon, likely in the setting of infectious/inflammatory entities, based on radiology report. No abscess or fluid collection noted. At that time, Streptococcus viridians (anginosus) sensitive to penicillin grew in the blood cultures. Transthoracic and transoesophageal echocardiography showed no vegetation. Even though the patient had bacteraemia with a microorganism known to cause infective endocarditis, he did not meet Duke criteria to make that diagnosis. Surveillance blood cultures also came out negative. No clear source of bacteraemia was found at that time, but given the findings on abdominal CT and poor dentition, it would most likely be in the intestine or oral cavity. Regarding anaemia and gastrointestinal bleeding, the patient had oesophagogastroduodenoscopy that showed gastric ulcers, for which the patient received proton pump inhibitor. Immunostaining for Helicobacter pylori was negative and biopsy was negative for malignant cells. Regarding atrial fibrillation, the patient was started on warfarin. The patient was discharged on treatment with penicillin and was instructed to follow-up with the gastroenterologist (colonoscopy) and dental workup. The patient was readmitted for gastrointestinal bleeding 1 week after discharge. On the second admission the patient’s blood pressure was 119/65 mm/Hg, heart rate 81 beats per minute, respiratory rate 18 breaths per minute, oxygen saturation of 96% on room air with a temperature of 99.2 degree Fahrenheit. The physical examination revealed mild pallor. The abdomen was soft non-tender, mildly distended and with hyperactive bowel sounds. No rebound, guarding or rigidity was noted. Digital rectal examination was grossly bloody. His laboratory data showed that haemoglobin and haematocrit were 8.5 and 26.1, respectively, and no leukocytosis or left shift. Oesophagogastro-duodenoscopy on the previous admission showed healing gastric ulcers, but no active bleeding. Since the digital rectal examination showed bright red blood, colonoscopy was pursued. The patient developed obstruction during the preparation. CT of the abdomen showed possible colonic pneumatosis and colonoscopy was abandoned at that time. Barium enema showed apple core lesion, suspicious of neoplasm 2
Mass at the level of the sigmoid colon.
at the level of distal sigmoid (figures 1 and 2). Endoscopy showed an obstructing mass at the level of sigmoid colon (figures 3 and 4). A stent was placed through the mass to relieve the obstruction. No samples were taken during the sigmoidoscopy, but macroscopic appearance was consistent with malignant lesion. Tumour markers showed a carcinoembryonic antigen level of 31.3. The patient was taken to the operating room and had a sigmoid colectomy with a descending end colostomy. Surgical pathology/cytology report showed invasive colonic adenocarcinoma. After the discharge, he has been followed by a haematology– oncology specialist for stage II T3 N0 colon cancer. He is feeling better and gaining weight.
DISCUSSION Since the first article in 19511 that suggested a correlation between S. bovis and colonic neoplasm, there has been growing evidence that established this correlation, identified both on clinical2–4 and laboratory studies.5–7 While for S. bovis there is enough evidence to pursue further workup, in a case of bacteraemia there is not yet a direct link between other species of Streptococcus viridians bacteraemia and colonic neoplasm with the exception of sporadic case reports like this one. Streptococcus viridians is a group of α-haemolytic or non-haemolytic streptococci found mostly in the oral cavity and gastrointestinal (GI) tract. S. bovis is part of this group as well. Streptococcus viridians usually have low virulence and would not cause sepsis unless there is some impaired immunity on the background and there is damage of the integrity of mucosa. In the case above the Streptococcus viridians (anginosus) bacteraemia seems to be an early signs of colonic neoplasm. As mentioned previously, there have been case reports that hint
Figure 4
Mass at the level of the sigmoid colon. Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
Unusual association of diseases/symptoms towards a correlation between species of Streptococcus viridians other than bovis, with colonic neoplasms.8–15 Even with these case reports, there has not been enough evidence to include a routine workup for colonic neoplasm in a patient with Streptococcus viridians bacteraemia, other than S. bovis, for which there is a well-established link. Furthermore, there are no definite studies to evaluate if proteins related with other species of Streptococcus viridians have any effect on carcinogenesis or angiogenesis. While further evidence is needed to warrant a GI workup in a patient with Streptococcus viridians bacteraemia other than bovis, we would like to increase the awareness in the physicians’ community regarding unexplained bacteraemia due to other species of Streptococcus viridians. This would be especially relevant for patients who have no GI screening, as Streptococcus viridians bacteraemia can be an early sign of colonic neoplasm. In the case above, the patient had Streptococcus anginosus bacteraemia, which despite being part of Streptococcus viridians group, is mostly associated with abscess formation, rather than infective endocarditis.
Contributors AM identified and managed the patient, wrote the manuscript and conducted the literature review. TA was mostly involved in the literature review and the final presentation. AM and TA are the guarantors. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2
3 4
5
6
Learning points ▸ In the case of unexplained bacteraemia thorough workup is needed to identify the source. ▸ Physicians need to be aware that Streptococcus viridians, other than Streptococcus bovis, bacteraemia can be an early sign of colonic neoplasm. ▸ Gastrointestinal workup may be warrantied in certain cases of Streptococcus viridians bacteraemia, other than bovis, as it can reveal colonic neoplasm. ▸ Identification of microorganism at the level of species it is very helpful, since it gives you clues towards the complications and associations. ▸ In case of iron deficiency anaemia both upper and lower endoscopy should be performed, even in the case when upper endoscopy has revealed a source, since other sources can be missed.
7
8
9
10 11 12 13 14 15
McCOY WC, Mason JM III. Enterococcal endocarditis associated with carcinoma of the sigmoid; report of a case. J Med Assoc State Ala 1951;21:162–6. Corredoira-Sánchez J, García-Garrote F, Rabuñal R, et al. Association between bacteremia due to Streptococcus gallolyticus subsp. gallolyticus (Streptococcus bovis I) and colorectal neoplasia: a case-control study. Clin Infect Dis 2012;55:491–6. Gold JS, Bayar S, Salem RR. Association of Streptococcus bovis bacteremia with colonic neoplasia and extracolonic malignancy. Arch Surg 2004;139:760–5. Alazmi W, Bustamante M, O’Loughlin C, et al. The association of Streptococcus bovis bacteremia and gastrointestinal diseases: a retrospective analysis. Dig Dis Sci 2006;51:732–6. Biarc J, Nguyen IS, Pini A, et al. Carcinogenic properties of proteins with pro-inflammatory activity from Streptococcus infantarius (formerly S. bovis). Carcinogenesis 2004;25:1477–84. Ellmerich S, Schöller M, Duranton B, et al. Promotion of intestinal carcinogenesis by Streptococcus bovis. Carcinogenesis 2000;21:753–6. Burnett-Hartman AN, Newcomb PA, Potter JD. Infectious agents and colorectal cancer: a review of Helicobacter pylori, Streptococcus bovis, JC virus, and human papillomavirus. Cancer Epidemiol Biomarkers Prev 2008;17:2970–9. Lin CY, Chao PC, Hong GJ, et al. Infective endocarditis from Streptococcus viridans associated with colonic carcinoma: a case report. J Card Surg 2008;23:263–5. Tzur T, Liberman S, Felzenstein I, et al. Liver abscesses caused by Streptococcus milleri: an uncommon presenting sign of silent colonic cancer. Isr Med Assoc J 2003;5:206–7. Marinella MA. Streptococcus sanguis bacteremia associated with cecal carcinoma: case report and review of the literature. Am J Gastroenterol 1997;92:1541–2. Siegert CE, Overbosch D. Carcinoma of the colon presenting as Streptococcus sanguis bacteremia. Am J Gastroenterol 1995;90:1528–9. Macaluso A, Simmang C, Anthony T. Streptococcus sanguis bacteremia and colorectal cancer. South Med J 1998;91:206–7. Fass R, Alim A, Kaunitz JD. Adenocarcinoma of the colon presenting as Streptococcus sanguis bacteremia. Am J Gastroenterol 1995;90:1343–5. Kampe CE, Vovan T, Alim A, et al. Streptococcus sanguis bacteremia and colorectal cancer: a case report. Med Pediatr Oncol 1995;24:67–8. Legier JF. Streptococcus salivarius meningitis and colonic carcinoma. South Med J 1991;84:1058–9.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Mulita A, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-203695
3
