A 41‐year‐old man with a history of chronic plaque psoriasis and an appendectomy 3 months prior presented to our hospital with malaise, dyspnea, fever, and a productive cough for 1week. On arrival, the patient was hypotensive and in respiratory distress, with a multifocal pneumonia on chest x‐ray. He was admitted to the medical ICU for severe sepsis with hypoxic respiratory failure and was started on azithromycin, ceftriaxone, and vancomycin. On hospital day 3, the patient spiked a fever of 102°F. Further questioning into his medical history revealed that he had received adalimumab injections for 6 months due to chronic plaque psoriasis. His last injection was 3 months prior, shortly before he was admitted to a hospital in London with ruptured appendicitis, complicated by peritonitis, requiring 3 weeks of antibiotic therapy. Despite initial improvement, he noted that after discharge he experienced intermittent subjective fevers, poor oral intake, and night sweats, culminating in his presentation to our hospital. Blood cultures from this admission grew Streptococcus constellatus in 1 of 4 bottles. HIV testing was negative. Repeat chest x‐ray revealed a pleural effusion that was too small to drain. A chest CT was performed and incidentally demonstrated a hypogenicity in the liver. A right upper quadrant ultrasound confirmed the presence of a small liver abscess, unable to be drained. Metronidazole was added for anaerobic coverage. The patient began to improve clinically, and repeat blood cultures were negative. He was successfully discharged from the hospital on a 4‐week course of ceftriaxone and metronidazole.
S. constellatus is part of the S. Milleri group, a subgroup of viridans streptococci. It is part of the normal flora of the oral cavity and GI tract. It is important to properly interpret positive blood cultures for these organisms because, unlike other viridans strep, they are rarely contaminants. Local infection with this organism is relatively common and well defined in clinical practice. However, bacteremia is less frequent. Systemic infections, including appendicitis, brain and liver abscesses, and sepsis, have been demonstrated in children, cystic fibrosis patients, diabetics, organ transplant recipients, and cancer patients. In our case, we suspect that this patient's adalimumab use left him immunocompromised and susceptible to S. constellatus bacteremia.
In our case, a young man with a history of adalimumab use presented 3 months after prompt medical therapy for perforated appendicitis with sepsis due to S. constellatus, with a multifocal pneumonia and a liver abscess. The progression and spread of S. constellatus infection despite medical therapy and discontinuation of the immunosuppressant should serve as caution to providers treating the infectious complications of adalimumab therapy.
To cite this abstract:Bhagavath A, Krupka M, Calabrese R. Streptococcus Constellatus Bacteremia Associated with Complex Pulmonary and Hepatic Infections Following Perforated Appendicitis in a Patient Taking Adalimumab. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 325. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/streptococcus-constellatus-bacteremia-associated-with-complex-pulmonary-and-hepatic-infections-following-perforated-appendicitis-in-a-patient-taking-adalimumab/. Accessed July 22, 2019.