An 82-year-old male with a medical history of type 2 diabetes mellitus visited our department with consciousness disturbance, worsening dyspnea, and high grade fever. Chest X-ray revealed pulmonary edema and cardiomegaly. Brain MRI revealed multiple high intensity lesions, which were compatible with acute stroke. Blood culture was positive for Streptococcus bovis. TTE revealed no apparent vegetation in his cardiac valves. During stay in the ward, he presented with bloody stool. Colonoscopy revealed lateral spreading tumors (granular type) in sigmoid colon. Biopsied specimen was consistent with tubular adenoma. In this case, I think that his cerebellar infarction and worsening heart failure resulted from infective endocarditis caused by S. bovis. Apparently, the association between S. bovis and colon cancer has been reported. It is likely that septicemia and bacteremia by S. bovis can be caused by benign colon tumors and diverticulitis. (It was my failure not to think of performing TEE to reveal infective endocarditis.)
What do you think about this patient’s medical condition?
Greetings doctor Takeuchi.
My opinion is that you are certainly right. The clinical significance of blood cultures growing Streptococcus bovis group lies with gastrointestinal disorders including colon cancer. (Citation from "Manual of Clinical Microbiology" 10th edition, ASM).
Dear dr Takeuci,
thank you for sharing this intriguing case, and I think it is worth reporting, providing a detailed follow-up.
Since the association between bacteremia from S. bovis and colon cancer is well established, I always recommend colonoscopy in such cases.
If you be so kind, I wish to know something more about this patient. Has he any other risk factor for endocarditis (i.e. prosthetic or damaged heart valves, pace-maker and so on), and how did he do after diagnosis? How did you manage him? Cerebral lesions have evolved or stabilized? Do you begin anticoagulation? Do you referred him to the Surgeon?
If I could speculate, my opinion is - if the patient has not atrial fibrillation - that the most probable diagnosis is cerebral embolization from endocarditis provoked by bacteriemia from the colonic adenoma.
Thanks Alexander!
Thanks for giving me a good source about this microbe!
Nobuhiro
Dear Marco,
Thank you for providing valuable suggestions!
This is the case I encountered about four years ago. I should probably check the patient's medical history in details. His past medical history included DM and chronic heart failure which were treated by oral drugs. His ECG revealed normal sinus rhythm; there was no evidence of atrial fibrillation. The patient had no history of cardiac surgery, catheterization, or pace-maker implantation.
I vaguely remember that I didn't provide anticoagulant medication because I was afraid that potential endocarditis in this patient might develop endocarditis-related cerebral aneurysm (though there was no evidence of aneurysm by MRA). Despite our efforts to save the patient, his consciousness disturbance didn't improve and he died due to worsened heart failure.
I should probably think out this case.
Nobuhiro
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