(222) A Fishy Clot: Case of Inferior Vena Cava Thrombus in Streptococcus anginosus-Related Liver Abscess

Introduction: Streptococcus anginosus comprises a rare group of catalase-negative, gram-positive cocci implicated in various nasopharyngeal, pulmonary, and intra-abdominal infections. This bacterium normally colonizes the upper respiratory and gastrointestinal tract, but it may be acquired via environmental contamination such as direct contact with animals. An infrequent complication of it is the development of septic thrombi. Here we present a case of an elderly female with septic shock secondary to Streptococcus anginosus-related liver abscess and an incidental inferior vena cava (IVC) septic thrombus.

Description: A 74-year-old female with a history of hypertension and recent travel to Japan, presented with a chief complaint of abdominal pain and was admitted to the Medical Intensive Care Unit for septic shock in the setting of liver abscess confirmed by imaging. She was started on broad-spectrum intravenous antibiotics and the liver abscess was drained for source control. Liver aspirate grew Streptococcus anginosus. Upon routine point-of-care ultrasound (POCUS), the patient was found to have a thrombus in her IVC. Confirmatory transthoracic echocardiogram did in fact reveal an IVC thrombus. Vascular surgery was consulted who recommended repeat imaging to assess clot displacement, which showed no thrombus. Therefore, the decision was made not to initiate anticoagulation, especially since there was no resulting hemodynamic instability. Subsequently, the patient’s condition significantly improved, and she was discharged home.

Discussion: Streptococcus anginosus is a commensal of the human body, but there have been reports of its pathogenicity associated with consumption of contaminated food. This might have been the precipitating factor in this case as the patient endorsed consumption of possibly contaminated fish during her trip to Japan. Furthermore, the risk of septic thrombi should be kept in mind particularly when there is development of an abscess. Therefore, there may be a role of serial POCUS assessments in critically ill patients with septic shock due to Streptococcus anginosus abscesses.