(1467) The Virulent Viridans: An Interesting Case of Streptococcus constellatus Causing Septic Shock

Introduction: Septic shock caused by organisms of oral flora is rare but can be lethal. Streptococcus Constellatus belongs to Streptococcus Anginosus (SAG) group which are found in normal oropharyngeal and gastrointestinal (GI) flora. The bacteremia caused by SAG has been known to cause mortality in 10-16% of these patients. This organism can cause hematogenous spread to cause abscess of brain, liver, lungs and endocarditis. Most common identifiable risk factor is aspiration.

Description: This case describes a 67-year-old female with history of hypertension and tobacco use brought into the Emergency Department (ED) by the EMS after she was found to be in asystole at home. She underwent 2 rounds of cardiopulmonary resuscitation (CPR) and was intubated in the field. After achieving return of spontaneous circulation, patient arrived at the ED. Per patient’s husband, the patient slid off the couch and found to be unresponsive on the floor. On arrival to the ED this time, patient noted to be hypotensive and was adequately fluid resuscitated, started on norepinephrine and vasopressin along with one dose of piperacillin-tazobactam. Labs showed findings consistent with severe sepsis. Further imaging was ordered, and patient was admitted to the Intensive Care Unit (ICU) for further management. CT chest showed multiple filling defects of left lower lobe concerning for aspiration. CT abdomen showed multiple large hypointense masses concerning for liver abscess with portal vein thrombosis, Patient was started on ceftriaxone and metronidazole. General surgery was consulted, and patient was immediately taken for exploratory laparotomy where multiple liver abscesses was drained. Soon after returning from the operation room, patient developed ST segment elevation in leads V1-V4, cardiology was consulted but no further intervention could be done given hemodynamic instability in the setting of bacteremia. Patient was coded at bedside but finally succumbed to her illness. Deep wound cultures later grew Streptococcus constellatus which is a common organism found in the oral cavity but rarely causes sepsis leading to mortality as above.

Discussion: A complete history and thorough oral exam with close follow-up in case of periodontal infection might improve outcome for population at risk of sepsis due to oral microbes.