New York Hospital Queens Flushing, NY, United States
Seunghyup Baek, DO, Jason Cohen, MD, Samson Ferm, MD, Constantine Fisher, MD, Miri Kim, MD, Joann Wongvravit, DO, Syed Hussain, MD, Sang Hoon Kim, MD New York Hospital Queens, Flushing, NY
Introduction: Streptococcus salivarius, a gram-positive, facultative anaerobic bacteria is part of the normal flora within the oral cavity, thus bacteremia secondary to S. salivarius without oral lesion is rare. Post-endoscopic retrograde cholangiopancreatography (ERCP) bacteremia is commonly caused by gram-negative species. We present a rare case of an ERCP followed by S. salivarius bacteremia without an identifiable oral source.
Case Description/Methods: A 62-year-old male with a past medical history of diabetes mellitus and hypertension was referred with persistent right upper quadrant (RUQ) pain. A computed tomography scan showed a common bile duct (CBD) stricture. Elective ERCP showed normal caliber CBD with sludge. A sphincterotomy was performed, the duct was swept, and stents were placed within CBD and pancreatic duct (figure 1). Post-discharge, patient reported worsening RUQ pain, nausea, emesis, and fever. He presented to the ER. Vital signs were stable. On exam, he was tender to palpation in the RUQ without guarding or rigidity. Lab showed lactate 2.8 mmol/L, WBC 14.4 K/uL, lipase 46 U/L, total bilirubin 9.3 mg/dL, direct bilirubin 6.3 mg/dL, indirect bilirubin 3 mg/dL, ALP 101 U/L. Bilirubin trended down. Piperacillin/Tazobactam was started as empiric coverage. Blood cultures grew S. salivarius. IV vancomycin was started, and transitioned to daptomycin at discharge. Oral surgery evaluation showed no odontogenic nidus of infection. A hepatobiliary iminodiacetic acid scan with cholecystokinin demonstrated a depressed gallbladder ejection fraction consistent with biliary dyskinesia. At one month follow up, patient reported with mild abdominal discomfort. Lab reflected resolution of infection. Laparoscopic cholecystectomy was performed three months later, which completely resolved abdominal discomfort.
Discussion: The reported incidence of bacteremia secondary to ERCP is 6.4 to 18% and occurs often in patients with biliary obstruction. ASGE guidelines recommend against antibiotic prophylaxis before ERCP if obstruction is not suspected or complete biliary drainage is anticipated. When bacteremia occur, it often involves gram negative organisms. S. salivarius bacteremia is presumed to originate from minor trauma within the oral cavity, where it is prevalent. Our aim is to add to the body of literature regarding post-ERCP infection; this case is noteworthy in that bacteremia involved an unexpected organism without a perceptible nidus of infection.
Figure: Figure 1. Plastic stent in place within CBD and pancreatic duct
Disclosures: Seunghyup Baek indicated no relevant financial relationships. Jason Cohen indicated no relevant financial relationships. Samson Ferm indicated no relevant financial relationships. Constantine Fisher indicated no relevant financial relationships. Miri Kim indicated no relevant financial relationships. Joann Wongvravit indicated no relevant financial relationships. Syed Hussain indicated no relevant financial relationships. Sang Hoon Kim indicated no relevant financial relationships.
Seunghyup Baek, DO, Jason Cohen, MD, Samson Ferm, MD, Constantine Fisher, MD, Miri Kim, MD, Joann Wongvravit, DO, Syed Hussain, MD, Sang Hoon Kim, MD. P2786 - Bacteremia From ERCP? A Rare Case of Streptococcus salivarius Bacteremia After ERCP Without Oral Lesion, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
