Abiotrophia defectivatriple threat: A rare case of infective spondylodiscitis, endocarditis, and brain abscess

Abstract

Abiotrophia defectiva is a pathogen of the oral, gastrointestinal, and urinary tracts that can cause significant systemic disease with uniquely negative blood cultures depending on the growth medium. Prior cases note possible seeding from relatively common procedures such as routine dental work and prostate biopsies, however case literature describes prior infectious complications to include infective endocarditis, brain abscess formation, and spondylodiscitis. While prior cases describe some aspects of these presentations, we highlight a case of a 64-year-old male who presented to the emergency department (ED) f5or acute onset of low back pain with fever symptoms four days after an outpatient transrectal ultrasound-guided needle biopsy of the prostate, with a prior dental extraction described four weeks prior to arrival. Findings on initial ED presentation and subsequent hospitalization revealed infective spondylodiscitis, endocarditis, and brain abscess formation. This is the only cases noted in literature with all three infection locations with dual risk factors of dental and prostate procedures prior to symptom onset. This case highlights the multifocal illness that can complicate Abiotrophia defectiva infections, and the importance of thorough ED evaluation and multiservice approach for consultation and treatment.

1 Case

A 64-year-old male presented to the emergency department (ED) complaining of acute onset of severe low back pain four days after an outpatient transrectal ultrasound-guided needle biopsy of the prostate (TUGNBP). Prior to the procedure, he denied any urinary symptoms of frequency, urgency, or pain, and denied any significant history of urinary tract infections. Approximately eight hours after the procedure, the patient noted the onset of pain, made so severe with ambulation that he reported crawling as his only means of self-mobility. Use of naproxen, acetaminophen and transdermal lidocaine provided no relief. He endorsed chills and numbness to the lateral left thigh, and notably admitted reported no bowel movements since the TUGNBP. He denied urinary incontinence or retention, saddle paresthesias, lower extremity weakness, or rashes or lesions of the genitals or perineum. Significant medical history included a known schwannoma at the fifth lumber vertebrae.

In the ED, initial triage revealed no abnormal vital signs, including an oral temperature of 36.1C. Initial exam revealed decreased flexion strength of the left and right hips, with additional decreased active hip flexion range of motion bilaterally secondary to increased back pain, however straight leg raise did not produce sciatica symptoms. Direct examination of the back revealed minimally appreciable edema around the lumbar spine, but otherwise without any bony tenderness, edema, erythema or any rashes or lesions. Abdominal examination found only left lower quadrant tenderness. Cardiac auscultation revealed an apical holosystolic murmur, however on questioning the patient stated he had been told of this one month prior to ED presentation at a routine primary care appointment. Examination of the chest, abdomen, and musculoskeletal systems were otherwise unremarkable.

Given initial constipation history and localized tenderness on exam, diverticulitis was considered prompting computed tomography (CT) without intravenous (IV) contrast due to regional shortages. Initial management using ketorolac 15 mg IV, acetaminophen 1 g IV, 1 L saline, and diazepam 5 mg IV for possible paraspinal spasms brought no relief. Laboratory findings revealed a urinalysis (UA) with ketones, red blood cells and proteinuria ( Table 1 ). Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 101 mm/h and 13.2 mg/L, respectively. Other remaining lab work, including complete blood count, comprehensive metabolic panel, and lipase did not demonstrate any significant abnormalities.

Table 1

Laboratory values on emergency department presentation.

Test	Patient result	Reference range
WBC (x 10 ⁶/uL)	10.7	4.15–10.6
Hgb (g/dL)	14.2	13.0–18.0
Hct (%)	42	39–51
Plts (x 10 ³/uL)	262	140–420
Neutrophil %	80.5	38.5–76.5
Lymphocyte %	10.6	14.0–46.0
Monocyte %	7.9	3–13.0
ESR (mm/h)	101	0–20
CRP (mg/dL)	13.2	0.04–0.50
Sodium (mmol/L)	138	135–145
Potassium (mmol/L)	3.40	3.50–5.10
Chloride (mmol/L)	100	98–107
CO2 (mmol/L)	25	22–31
BUN (mg/dL)	23.0	6.0–23.0
SCr (mg/dL)	0.69	0.60–1.20
Glucose (mg/dL)	139	74–109
Lactic Acid (mmol/L)	0.8	0.5–2.2
Urinalysis
Glucose	Negative	Negative
Ketones	40+	Negative
Blood	Large	Negative
Protein	100 mg/dL	Negative
Nitrite	Negative	Negative
Leukocyte Esterase	Trace	Negative
WBC (per HPF)	1	≤4
RBC (per HPF)	245	0–8
Bacteria	Negative	Negative
Epithelium (per HPF)	1	0–3