St. Vincent's Medical Center, Quinnipiac University Bridgeport, CT, United States
Rishi Chadha, MD1, Jean-Michel Oquet, MD1, Julia Kostka, MD1, Aleksandra Rosinski, MD2 1St. Vincent's Medical Center, Quinnipiac University, Bridgeport, CT; 2St. Vincent's Medical Center, Bridgeport, CT
Introduction: Infective endocarditis has been shown to be a strong marker for prevalent occult cancer and a predictor of modestly increased long-term cancer risk. Here we describe a patient that presented with Enterococcus faecalis (E. faecalis) endocarditis and later Streptococcus gallolyticus (S. gallolyticus) bacteremia which led to the diagnosis of adenocarcinoma of the ascending colon.
Case Description/Methods: 51-year-old male with a medical history of hypertension, hypercholesterolemia, and type 2 diabetes mellitus presented to the hospital with a one-month history of gait instability. Cranial imaging showed left basilar ganglion, superior frontal, parietal and occipital hypodensities with petechial hemorrhage indicating embolic stroke. Blood cultures were positive for E. faecalis and patient was started on IV antibiotics. TEE showed a small 0.5cmx0.4 cm mobile vegetation on the anterior mitral valve leaflet and a large 1.7cmx0.8cm highly mobile vegetation on the aortic valve. CTA was done for valve repair workup and showed hypodensities in the spleen indicative of splenic infarcts. Patient underwent aortic and mitral valve. Patient was discharged and completed 6-week IV antibiotic course. Months later, patient returned to the hospital with fevers and chills. Blood cultures were positive for S. gallolyticus. Patient was started on Ampicillin and Vancomycin, later reduced to a 6-week course of Penicillin G. TEE was negative for vegetations. Patient underwent colonoscopy showing 3-4 cm mass in the ascending colon with pathology confirming adenocarcinoma. Patient underwent segmental colectomy with pathology and lymph node biopsy indicating T2N0 stage.
Discussion: E. faecalis and S. gallolyticus are both considered opportunistic pathogens. While S. gallolyticus is more commonly associated with colorectal cancer, direct correlation between E. faecalis infection and colorectal cancer has not yet been well established. Rat models have shown that reactive oxidative species and extracellular superoxide produced by E. faecalis causes genomic instability which could predispose the host to mutations. In the case of both bacteria, the source of infection is commonly endogenous with a translocation process through the intestinal barrier. This process occurs due to pathological conditions such as pancreatitis, trauma, surgery, or cytotoxic drugs. In the case of our patient, adenocarcinoma of the ascending colon likely led to compromise of the intestinal epithelium predisposing him to both endocarditis and bacteremia.
Figure: FIGURE A: TEE image of 0.5 cm x 0.4 cm mobile vegetation on the atrial aspect of the anterior mitral valve leaflet. FIGURE B: TEE image of 1.7 cm x 0.8 cm highly mobile vegetation on the aortic valve. FIGURE C: Axial non-contrast CT head showing sub-cortical area of hypodensity in the left temporal lobe concerning for embolic infarct. FIGURE D: Axial post-contrast CT abdomen image showing peripheral wedge-shaped area of low attenuation consistent with splenic infarct which was found on TAVR work up. FIGURE E: A 3-4 cm tubulovillous adenoma in the descending colon. FIGURE F: Coronal post-contrast CT chest and abdomen image showing hypodense filling defects around the aortic valve replacement prosthesis concerning for vegetations or thrombi.
Disclosures: Rishi Chadha indicated no relevant financial relationships. Jean-Michel Oquet indicated no relevant financial relationships. Julia Kostka indicated no relevant financial relationships. Aleksandra Rosinski indicated no relevant financial relationships.
Rishi Chadha, MD1, Jean-Michel Oquet, MD1, Julia Kostka, MD1, Aleksandra Rosinski, MD2. P2329 - Enterococcus faecalis Endocarditis and Streptococcus gallolyticus Bacteremia in a Patient With Adenocarcinoma of the Descending Colon, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
