(1228) A Rare Case of Streptococcus intermedius Empyema in an Immunocompetent Patient

Introduction: Streptococcus intermedius is a group of commensal bacteria found in the oropharynx and upper respiratory tract and can cause serious infection in immunosuppressed patients. We report a rare case of Streptococcus intermedius empyema and bronchopleural fistula in an immunocompetent patient.

Description: A 58-year-old female with a past medical history of bipolar disorder and COVID-19 infection one month prior presented to the emergency room with a three-week history of fever, shortness of breath, non-productive cough, and left-sided back pain. On examination, she was afebrile, saturating 95% on room air, and had decreased breath sounds in the left lung. Labs were significant for hemoglobin 8.4 g/dL, WBC 18.0 and platelet 1059 10*3/µL. CT chest demonstrated large cavitary lesions with air-fluid levels along the left lung periphery and a 13.9 x 7.6 x 17 cm empyema with bronchopleural fistula causing left lung compression. She was started on broad-spectrum antibiotics and subsequently underwent left robotic thoracoscopy with total decortication. The empyema was drained and three chest tubes were placed in the left pleural cavity which were subsequently removed on postoperative day 2, 3 and 6. Pleural fluid culture grew Streptococcus intermedius and antibiotics were changed to ampicillin. The patient was eventually discharged home on oral antibiotics for four weeks.

Discussion: Streptococcus intermedius is part of the Streptococcus angiosus (SAG) group of organisms which commonly cause brain and abdominal abscesses in immunosuppressed patients. Pleuropulmonary infection with SAG group is rare and occurs in those with risk factors of smoking, alcohol abuse, dental illness, malignancy, liver cirrhosis, COPD, or diabetes. Treatment involves invasive procedures such as thoracotomy for pleural decortication, chest tube insertion for drainage, and antibiotic therapy. In this case, patient presented with extensive empyema and bronchopleural fistula in the absence of immunosuppression or significant comorbidities, which is an uncommon clinical presentation for Streptococcus intermedius. This case also suggests the need for further investigation into a possible association between SARS-CoV-2 and SAG.