Acute cholecystitis and bacteraemia due to Streptococcus bovis biotype II.

Streptococcus bovis (SB) is a gram-positive, catalase negative, facultative anaerobic coccus that forms part of the usual flora in the digestive system of 10% of healthy people.1 SB belongs to the “bovis” group or Group D streptococci. This Group contains various species: S. equinus, S. gallolyticus (subspecies galactolyticus -biotype I – and pasterianus – biotype II/2), S. infantarius (SB biotype II/1), and S. alactolyticus. SB biotype I, the most common in our area, is more closely relatedwith colorectal cancer and SB biotype II/1with non-colonic cancers.2–5 Theusual portal of entrance is the digestive system, though other portals exist, such as the urinary tract.6 The most typical clinical presentation of SB infection is bacteraemia, being the second leading cause of streptococcal endocarditis.7 Although the diseasemost commonly associatedwith SB bacteraemia is colon cancer, SB bacteraemia has also been linked to other noncolonic neoplastic diseases, both digestive (gallbladder, pancreas, duodenum) and non-digestive (lung, ovaries, and even haematological cancer)8,9 and with non-neoplastic digestive diseases, such as inflammatory bowel disease6 or liver disease.8,10 However, its involvement in processes related with diseases of the bile tract is unusual, with very few cases reported.11 We present a new case of SB bacteraemia associated with acute cholecystitis and review the cases published to date. The patient was a 73-year-old man with a history of ischaemic heart disease, hypertension and insulin-dependent diabetes mellitus. He presented with a 24-hour history of periumbilical abdominal pain and vomiting of food. The patient had a temperature of 39 C, a blood pressure of 120/70mmHg, cutaneous-mucous jaundice and pain in the right hypochondrium, with no signs of peritoneal irritation. A blood test showed 17,000 leukocytes/mm3 with a left shift, creatinine 1.8mg/dL, AST 48 IU/L, ALT 101 IU/L, alkaline phosphatase 257 IU/L and bilirubin 2.48mg/dL, whichwas mainly the direct fraction. Empirical antibiotic therapy was started with intravenous ceftriaxone 2g/d. An abdominal-pelvic scan showed biliary lithiasis, and slight thickening and oedema of the gallbladder wall with radiographic signs of cholecystitis. The blood culture isolated S. bovis, biotype II sensitive to penicillin, by API 20 Strept (BioMérieux SA, Marcy l’Etoile, France). The patient therefore continued antibiotic treatment for 14 days with an excellent clinical and analytical resolution. Serological testing for hepatotropic viruses was negative. An echocardiogram and a colonoscopic study were normal. The subdivision of SB into three biotypes, I, II/1 and II/2, canhave clinical importance as regards decisionmaking. Bacteraemia due to biotype I, for example, is more often associated with endocarditis Table 1 Cases of bacteraemic cholecystitis/cholangitis due to S. bovis