dWe present a case of infective endocarditis caused by Streptococcus dysgalactiae subsp. dysgalactiae, a major cause of bovine mastitis and previously thought to be an animal-restricted pathogen. The patient reported no direct contact with animals, and the clinical course was severe and complicated.
CASE REPORTA 65-year-old male patient was admitted to Haukeland University Hospital in western Norway with radiating pain in his left shoulder, fever, and muscle ache. One month earlier, he had been admitted to a hospital in Spain with similar symptoms but was rapidly discharged with a diagnosis of shoulder tendinitis. He had a family history of sudden cardiac death, and his previous medical history included hypertrophic obstructive cardiomyopathy and a normal coronary angiography 7 years prior to the actual admission.Upon admission, he had a pulse rate of 100/min, a temperature of 39°C, and a respiratory frequency of 24/min, thus fulfilling the criteria of systemic inflammatory response syndrome (SIRS). He was pale, with a blood pressure of 118/59 mm Hg, and a holosystolic murmur was heard at the apex. No local signs of infection were observed over his left shoulder.The initial blood chemistry results were as follows, with normal range values in parentheses: hemoglobin, 8.5 g/dl (13.4 to 17.0 g/dl); C-reactive protein, 277 mg/liter (Ͻ5 mg/liter); leukocytes, 20.8 ϫ 10 9 /liter (3.5 ϫ 10 9 to 11.0 ϫ 10 9 /liter); neutrophils, 18.5 ϫ 10 9 /liter (1.7 ϫ 10 9 to 8.2 ϫ 10 9 /liter); sedimentation rate, 102 mm/h (0 to 20 mm/h); procalcitonin, 12.1 g/liter (Ͻ0.10 g/ liter); and troponin T, 896 ng/liter (Ͻ25 ng/liter). Thrombocytes were within the normal range. The electrocardiogram (ECG) demonstrated ST segment elevation in leads V 1 and V 2 and T inversion in leads V 4 to V 6 , indicative of ischemia.Antibiotic therapy was started on day 1 and included meropenem and vancomycin. A broader initial regimen than that recommended in the Norwegian National Antibiotic Guidelines was chosen since the patient had recently been admitted to a hospital in Spain. The following day, all four blood cultures grew nonhemolytic bacteria on blood agar. Species identification was performed using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and showed that the isolate was Streptococcus dysgalactiae. Subsequently, group C carbohydrate specificity was documented using a slide agglutination test (Oxoid, Cambridge, United Kingdom). The antimicrobial susceptibility testing showed that the group C streptococcus (GCS) isolate was fully susceptible to all tested antibiotics, with the following MICs: penicillin G, 0.008 mg/liter; ceftriaxone, Ͻ0.016 mg/liter; clindamycin, 0.25 mg/liter; vancomycin, 0.25 mg/liter; teicoplanin, 0.25 mg/liter; and linezolid, 1 mg/liter.A more thorough anamnestic interview revealed a history of weight loss of 6 kg, bloody stools, increasing pain in the left shoulder, and inaccuracy of vision. On examination, he had no peripheral vascular phenomena indicative of septic emboliz...