This report describes the first case of persistent bacteremia with endocarditis caused by Pediococcus acidilactici in a 32-year-old male with a history of short gut syndrome following a small bowel transplant. The results showed the utility of sequencing the intergenic spacer region for species identification and successful treatment using daptomycin.
CASE REPORTA 32-year-old male with a history of short gut syndrome following a small bowel transplant 1 year prior with severe rejection requiring explantation 3 weeks after transplant presented with fever (102°F), rigors, and dyspnea of 3 days' duration. His medical history included multiple abdominal surgeries, hepatosteatosis, and diabetes mellitus. He was total parenteral nutrition (TPN) dependent due to short bowel syndrome, with a history of multiple bacterial and fungal line infections. He denied any use of intravenous drugs. The review of systems was positive for dry cough, palpitations, and diffuse myalgias. On the physical examination, the patient was febrile (101.8°F) and his lungs were clear, with no heart murmur, conjunctival hemorrhage, splinter hemorrhages, Janeway lesions, or Osler nodules noted. The laboratory data showed a normal white blood cell count and differential, anemia (hemoglobin of 8.2 g/dl), and mild thrombocytopenia (114,000 cells/microliter). A chest X-ray performed upon admission showed bilateral patchy opacities. He was started on empirical treatment with vancomycin, piperacillin-tazobactam, and micafungin for a suspected line infection. A computer tomography (CT) scan of the chest with intravenous contrast showed multiple bilateral lung nodules suggestive for septic emboli. A transesophageal echocardiogram (TEE) exam showed a subcentimeter vegetation on the mitral valve, as well as a small patent foramen ovale with right to left shunt. He remained febrile during the following 4 days despite broad-spectrum antibiotics. Six sets of blood cultures (standard aerobic and anaerobic media [Bactec System, BD Diagnostics, Franklin Lakes, NJ]) drawn from the central line and peripherally over the next 5 days of hospitalization were Gram stain positive for Gram-positive cocci in clusters after 24 to 27 h of incubation at 37°C. The catheter tip culture following removal (day 5 of hospitalization) also was positive for a nonhemolytic, catalase-negative, Gram-positive coccus in clusters. Subsequent biochemical analysis showed all isolates to be negative for the production of pyrrolidonyl arylamidase (PYR test), positive for the production of leucine aminopeptidase and for the ability to grow in 6.5% NaCl, and resistant to vancomycin for a presumptive identification of the blood culture and catheter tip isolates as a Pediococcus species. At the time of positive blood cultures, micafungin and vancomycin were discontinued and the patient was on only piperacillin-tazobactam. The patient met the Duke criteria for infectious endocarditis. Given the persistent low-grade fever on the appropriate antibiotic therapy, as well as persistent positive blood c...