Multiple liver abscesses with isolation of streptococcus intermedius related to a pyogenic dental infection in an immuno-competent patient
© I. Holzapfel Publishers 2010
Received: 20 February 2010
Accepted: 21 May 2010
Published: 26 July 2010
Streptococcus intermedius - a member of the Streptococcus anginosus group - is part of the normal microbial flora of the oral cavity. Despite being regarded as a harmless apathogenic commensal, Streptococcus intermedius has been described to cause abscesses in various locations of the body.
We report the clinical case and course of treatment of a 18-year-old male patient presenting with multiple hepatic abscesses associated with an untreated pyogenic dental infection.
Streptococcus intermedius can cause liver abscesses emerging from dental infectious foci even in previously healthy patients without underlying innate or aquired immunodeficiency. The case illustrates the potential danger and underestimated risk associated with untreated dental infections.
Streptococcus intermedius is a member of the "Streptococcus anginosus group" (consisting of S. intermedius, S. constellatus, and S. anginosus), formerly also known as "Streptococcus miller group" or "Streptococcus intermedius group". Streptococcus intermedius is a spherical or ovoid, microaerophilic/anaerobic gram positive bacterium forming pairs or chains . The members of the Streptococcus anginosus group are frequently found in the human oral cavity, where they are considererd to be harmless commensals. They can also colonize the throat, nasopharynx, gastrointestinal tract, and genitourinary tract (which probably represents spread from the oral cavity). within the Streptococcus anginosus group, Streptococcus intermedius is most commonly found in dental plaques . Members of the S. anginosus group are regularly isolated from dental abscesses [3, 4] and have frequently been found to cause local and metastatic purulent infections [5, 6]. In particular Streptococcus intermedius has been reported to cause liver and brain abscesses (and rarely infective endocarditis) [2, 7–11]. As commensal organism of the intestinal tract members of the S. anginosus group have also been found to cause various infections within the abdominal cavity including liver abscesses, peritonitis, pelvic and subphrenic abscesses, appendicitis, abdominal wound infections and cholangitis [5, 12, 13]. Aspiration of commensal oropharyngeal Streptococcus anginosus can lead to pneumonia, lung abscess, and pleural empyema [3, 14–17]. Other infections caused by members of the Streptococcus anginosus s group are peritonsillar abscesses , mediastinitis , osteomyelitis , septic arthritis , and soft tissue infections [3, 21, 22]. An interesting feature of Streptococcus intermedius is the ability to replicate more rapidly in an environment with other microbes (e.g. Eikenella corrodens and anaerobes): It has been shown in vitro, that Streptococcus intermedius grows exponentially in mixed culture with E. cor rodens within 6 hours post inoculation, in comparison to 25 hours without E. corrodens . A possible clinical correlate of such a mixed infection has been described . In a murine model of pneumonia a synergistic effect between members of the S. anginosus group and oral anaerobes has been published (higher mortality, more histopathologic abnormalities and more viable bacteria in the lungs of mice with mixed infections than in the lungs of mice with monomicrobial infection) .
Our reported case corroborates published literature reporting Streptococcus intermedius as a cause of liver abscesses emerging from dental infectious foci even in previously healthy patients without underlying innate or aquired immunodeficiency [9, 24]. The case illustrates the potential danger and underestimated risk associated with untreated dental infections.
- Mirzanejad Y, Stratton CW: Streptococcus anginosus Group. In Principles and practice of infectious diseases. Philadelphia: Elsevier Churchill Livingstone Edited by: Mandell GL, Bennett JE, Dolin R. 2005, 2451–2455.Google Scholar
- Whiley RA, Beighton D, Winstanley TG, Fraser HY, Hardie JM: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus (the Streptococcus milleri group): association with different body sites and clinical infections. J Clin Microbiol 1992,30(1):243–244.PubMed CentralPubMedGoogle Scholar
- Molina JM, Leport C, Bure A, Wolff M, Michon C, Vilde JL: Clinical and bacterial features of infections caused by Streptococcus milleri. Scand J Infect Dis 1991,23(6):659–666. 10.3109/00365549109024289PubMedView ArticleGoogle Scholar
- Robertson D, Smith AJ: The microbiology of the acute dental abscess. J Med Microbiol 2009,58(2):155–162. 10.1099/jmm.0.003517-0PubMedView ArticleGoogle Scholar
- Gossling J: Occurrence and pathogenicity of the Streptococcus milleri group. Rev Infect Dis 1988,10(2):257–285. 10.1093/clinids/10.2.257PubMedView ArticleGoogle Scholar
- Whitworth JM: Lancefield group F and related streptococci. J Med Microbiol 1990,33(3):135–151. 10.1099/00222615-33-3-135PubMedView ArticleGoogle Scholar
- Woo PC, Tse H, Chan KM, Lau SK, Fung AM, Yip KT, et al.: "Streptococcus milleri" endocarditis caused by Streptococcus anginosus. Diagn Microbiol Infect Dis 2004,48(2):81–88. 10.1016/j.diagmicrobio.2003.09.011PubMedView ArticleGoogle Scholar
- Rashid RM, Salah W, Parada JP: 'Streptococcus milleri' aortic valve endocarditis and hepatic abscess. J Med Microbiol 2007,56(2):280–282. 10.1099/jmm.0.46781-0PubMedView ArticleGoogle Scholar
- Tran MP, Caldwell-McMillan M, Khalife W, Young VB: Streptococcus intermedius causing infective endocarditis and abscesses: a report of three cases and review of the literature. BMC Infect Dis 2008, 8: 154. 10.1186/1471-2334-8-154PubMed CentralPubMedView ArticleGoogle Scholar
- Mathisen GE, Johnson JP: Brain abscess. Clin Infect Dis 1997,25(4):763–779. 10.1086/515541PubMedView ArticleGoogle Scholar
- Libertin CR, Hermans PE, Washington JA: Beta-hemolytic group F streptococcal bacteremia: a study and review of the literature. Rev Infect Dis 1985,7(4):498–503. 10.1093/clinids/7.4.498PubMedView ArticleGoogle Scholar
- Murray HW, Gross KC, Masur H, Roberts RB: Serious infections caused by Streptococcus milleri. Am J Med 1978,64(5):759–764. 10.1016/0002-9343(78)90514-4PubMedView ArticleGoogle Scholar
- Hardwick RH, Taylor A, Thompson MH, Jones E, Roe AM: Association between Streptococcus milleri and abscess formation after appendicitis. Ann R Coll Surg Engl 2000,82(1):24–26.PubMed CentralPubMedGoogle Scholar
- Shinzato T, Saito A: The Streptococcus milleri group as a cause of pulmonary infections. Clin Infect Dis 1995,21(Suppl 3):S238-S243.PubMedView ArticleGoogle Scholar
- Wong CA, Donald F, Macfarlane JT: Streptococcus milleri pulmonary disease: a review and clinical description of 25 patients. Thorax 1995,50(10):1093–1096. 10.1136/thx.50.10.1093PubMed CentralPubMedView ArticleGoogle Scholar
- Marinella MA, Harrington GD, Standiford TJ: Empyema necessitans due to Streptococcus milleri. Clin Infect Dis 1996,23(1):203–204. 10.1093/clinids/23.1.203PubMedView ArticleGoogle Scholar
- Porta G, Rodriguez-Carballeira M, Gomez L, Salavert M, Freixas N, Xercavins M, et al.: Thoracic infection caused by Streptococcus milleri. Eur Respir J 1998,12(2):357–362. 10.1183/09031936.98.12020357PubMedView ArticleGoogle Scholar
- Whiley RA, Hall LM, Hardie JM, Beighton D: A study of small-colony, beta-haemolytic, Lancefield group C streptococci within the anginosus group: description of Streptococcus constellatus subsp. pharyngis subsp. nov., associated with the human throat and pharyngitis. Int J Syst Bacteriol 1999,49(Pt 4):1443–1449.PubMedView ArticleGoogle Scholar
- Shishido H, Watanabe K, Matsumoto K, Murakami K, Sato K: Primary purulent mediastinitis due to Streptococcus milleri. Respiration 1997,64(4):313–315. 10.1159/000196696PubMedView ArticleGoogle Scholar
- Houston BD, Crouch ME, Finch RG: Streptococcus MG-intermedius (Streptococcus milleri) septic arthritis in a patient with rheumatoid arthritis. J Rheumatol 1980,7(1):89–92.PubMedGoogle Scholar
- Jackson DS, Welch DF, Pickett DA, Mukwaya GM, Kuhls TL: Suppurative infections in children caused by non-beta-hemolytic members of the Streptococcus milleri group. Pediatr Infect Dis J 1995,14(1):80–82.PubMedView ArticleGoogle Scholar
- Lunn JV, Rahman KJ, Macey AC: Streptococcus milleri infection. J Hand Surg Br 2001,26(1):56–57. 10.1054/jhsb.2000.0492PubMedView ArticleGoogle Scholar
- Young KA, Allaker RP, Hardie JM, Whiley RA: Interactions between Eikenella corrodens and 'Streptococcus milleri-group' organisms: possible mechanisms of pathogenicity in mixed infections. Antonie Van Leeuwenhoek 1996,69(4):371–373. 10.1007/BF00399626PubMedView ArticleGoogle Scholar
- Quinlivan D, Davis TM, Daly FJ, Darragh H: Hepatic abscess due to Eikenella corrodens and Streptococcus milleri: implications for antibiotic therapy. J Infect 1996,33(1):47–48. 10.1016/S0163-4453(96)92776-0PubMedView ArticleGoogle Scholar