P3D330: Streptococcus Gallolyticus Subspecies Pasteurianus Late-onset Sepsis with Rare Complications

Introduction: Streptococcus gallolyticus subsp. pasteurianus is a rare and increasingly recognized cause of neonatal sepsis and meningitis. While adult literature supports further diagnostic workup of gastrointestinal and cardiac pathology when a S. bovis species is identified in the bloodstream, no current recommendations exist in pediatric literature. We present, to our knowledge, the first reported case of a neonate with S. gallolyticus subsp. pasteurianus bacteremia with both necrotizing enterocolitis and infective endocarditis.

Case Description: We present a preterm infant male born at 33 +0 weeks of gestational age via emergent cesarean section. The patient was transferred to the Neonatal Intensive Care Unit (NICU) for continued respiratory support and management of prematurity. He was quickly weaned to room air on post-natal day one and otherwise had an uneventful NICU course. On day 27, the infant developed tachycardia, abdominal distension, guarding, and hypoactive bowel sounds. An abdominal X-ray was obtained, which showed distended bowel loops, multiple areas with reticular pattern, and areas along the distal colon concerning for pneumatosis intestinalis (Figure 1). Given X-ray and clinical findings, our patient was diagnosed with Necrotizing Enterocolitis (NEC), made NPO, and started on medical management. Shortly after initiating antibiotic treatment, previously drawn blood cultures resulted positive at 12hrs for Streptococcus gallolyticus subspecies pasteurianus. Upon review of the literature and noting a predilection for S. gallolyticus species to endocardial tissue, the decision was made to obtain echocardiography to evaluate for any evidence of endocarditis/arteritis. Echocardiogram showed an 8mm echo-lucent object within the remnant of the PDA concerning for vegetation (Figure 2). Ultimately, the decision was made to extend treatment to 28 days for an endocarditis treatment course. The remainder of our patient’s hospital course was uncomplicated and they were discharged home on hospital day 55.

Discussion: The ability to use genetic based classification has further advanced the taxonomy of S. bovis, now divided into S. bovis biotype I (S. gallolyticus subsp. gallolyticus) and S. bovis biotype II (S. gallolyticus subsp. pasteurianus). Although new technology allows for further speciation, most labs only report the organism as S. bovis unless requested to further specify species and subspecies. Once S. bovis is identified, adult literature recommends proper microbiological classification as well as diagnostic workup of both gastrointestinal and cardiac pathology. However, no current recommendations exist in pediatric literature. In terms of neonates, S. bovis mimics symptoms of group B streptococcus, therefore providers should maintain suspicion for S. bovis when working up meningitis and neonatal sepsis.

Conclusion: This case report highlights the potential for further work up in neonates once S. bovis is identified, including obtaining the proper microbiological classification, as well as gastrointestinal and cardiologic diagnostic work up.