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Philip A. Mackowiak, Liver Abscess Associated with Persistent Streptococcus anginosus Bacteremia, Clinical Infectious Diseases, Volume 41, Issue 3, 1 August 2005, Pages 352–353, https://doi.org/10.1086/431485
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A 48-year-old Samoan man presented to Tupua Tamasese Hospital in Apia, Samoa, with a 3-day history of abdominal pain and fever. Abdominal ultrasonography showed a liver abscess measuring 7 × 8 cm. Despite surgical drainage and therapy with intravenous amoxycillin and clavulanic acid, high intermittent fevers persisted. An α-hemolytic streptococcus was isolated from the surgical specimens. The patient was transferred to a private hospital in Auckland, New Zealand, for further management of his case. An additional laparotomy and surgical drainage of the abscess were performed. A moderate growth of mixed aerobic and anaerobic flora was isolated from an intraoperative pus swab sample. Intravenous therapy with benzyl penicillin and gentamicin for 2 days was followed by therapy with amoxycillin and clavulanic acid (given intravenously for 3 days and then given orally for 10 days). Three weeks later, the patient presented to Auckland City Hospital with rigors and abdominal pain. He was febrile (temperature, 39°C) and tender in his right upper quadrant, with no peritonism. Cultures of blood samples obtained at admission to the hospital grew Streptococcus anginosus that was susceptible to penicillin (MIC, 0.06 mg/L). An abdominal CT scan showed an ill-defined, heterogeneous lesion 6 cm in diameter in segments 2 and 3 of the liver (figure 1). A short, curvilinear density that extended from the inferior aspect of the lesion toward the pylorus of the stomach (figure 2) was thought to represent staples inserted at surgery. A percutaneous drain was placed, and S. anginosus, Finegoldia magna, and a Peptostreptococcus species were isolated from pus samples. Pending culture results, the patient was initially treated with intravenous cefuroxime and metronidazole. Subsequently, his treatment was changed to intravenous benzyl penicillin. Despite appropriate antibiotic therapy, fevers and rigors continued, and S. anginosus was isolated from blood cultures performed on day 8 and day 9 after admission to the hospital.
