Title : A rare case of viridans streptococci in a liver abscess in the context of esophageal cancer
Abstract:
Introduction: Liver abscesses caused by viridans streptococci are rare, especially in patients with underlying malignancies. These abscesses are typically polymicrobial and often linked to gastrointestinal or biliary pathology. The emergence of viridans streptococci as a primary pathogen raises concerns about bacterial translocation and mucosal injury in patients with esophageal cancer. This case highlights an unusual presentation of viridans streptococci in a liver abscess and septicemia in the context of esophageal cancer, likely secondary to a mucosal tear.
Case Description: A 59-year-old male with newly diagnosed distal esophageal cancer, not yet on chemotherapy, and a history of type 2 diabetes presented to the emergency department with fever, chills, diarrhea, and a persistent cough. On examination, he was febrile (102°F) and tachypneic, with otherwise normal vital signs. Laboratory studies showed leukocytosis (WBC 20.9× 10³/μL), elevated procalcitonin (3.36 ng/mL), mild transaminitis, and negative respiratory and gastrointestinal pathogen
panels.
CT imaging revealed an 8×8×9 cm hepatic lesion, concerning for an inflammatory or neoplastic process. A PET -CT performed one month prior had shown no liver abnormalities. Empiric treatment with intravenous vancomycin and piperacillin-tazobactam was initiated. CT-guided drainage of the hepatic lesion yielded 205 mL of purulent fluid. Cultures from both the abscess and blood grew viridans streptococci, confirming septicemia and liver abscess caused by this oral flora. The patient’s recent cancer diagnosis raised suspicion for bacterial translocation through a mucosal lesion in the esophagus.
Following infectious disease consultation, the patient was transitioned to outpatient therapy with intravenous ertapenem via a peripherally inserted central catheter (PICC) line. The patient remained stable post-drainage and was closely monitored for chemotherapy readiness. Ertapenem therapy was continued for 21 days to cover the expected nadir period. After 21 days, if the patient was expected to undergo further cycles of chemotherapy, infectious disease specialists recommended a prophylactic dose of Augmentin 875 mg orally every day.
Discussion and Conclusion: This case highlights the importance of recognizing atypical pathogens, such as viridans streptococci, in liver abscesses, particularly in patients with malignancies. Mucosal injury in esophageal cancer may facilitate bacterial translocation. Early diagnosis, tailored antimicrobial therapy, and drainage are essential for optimizing outcomes and enabling t imely initiation of oncologic treatment. As cancer therapies advance, multidisciplinary approaches remain crucial in managing the complex intersection of infection and malignancy.
