Open Journal of Obstetrics and Gynecology, 2012, 2, 235-238 OJOG Published Online September 2012 (
Intra-abdominal abscesses secondary to Streptococcus
anginosus infection in a postpartum patient: A case
report and review of the literature
Rehab Shabana1, Lindsay Berbiglia2, John Barnwell3, Ronald Cheek1, Mark Wolf4,
Bernard Gonik1
1Department of Ob s tetrics and Gynecology, Wayne State University School of Medicine/Detroit Medical Center, Detroit, USA
2Department of General Surgery, Detroit Medical Center, Detroit, USA
3Department of General Surgery, Wayne State University School of Medicine/Detroit Medical Center, Detroit, USA
4Department of Internal Medicine, Detroit Med ical Cent er, Detroit, USA
Received 24 March 2012; revised 30 April 2012; accepted 11 May 2012
Although rare, infection with Streptococcus angino-
sus has a known predilection for abscess formation.
We report here a case of a 20 year-old, otherwise
healthy female patient noted to have developed ab-
dominal and pelvic abscesses secondary to Strepto-
coccus anginosus infection. Although the inciting fo-
cus of the pathogen remains unclear in our patient,
this case report emphasizes the importance of rapid
identification of the organism and highlights the ap-
proach to therapeutic options in the management of
such cases.
Keywords: Streptoc occu s anginosus; Abdominal
A 20 year-old G4 P3-0-1-3 presented to the emergency
department seven days after spontaneous vaginal deli-
very of a term infant, complaining of worsening lower
abdominal pain since hospital discharge. Aside from a
first degree perineal laceration, which was repaired un-
eventfully, the entire prenatal course and delivery were
otherwise uncomplicated. She denied fever, nausea, vo-
miting or change in bowel function. Vital signs were
stable except for a resting tachycardia of 118 bpm. Tem-
perature was 36.3˚C. Pertinent physical exam findings
included a distended abdomen which was soft, mildly
tender in all quadrants, with bowel sounds present, and
without rebound or guarding. A small non-tender, re-
ducible umbilical hernia was also appreciated on exam.
The uterus was well involuted below the umbilicus and
non-tender. Pelvic exam revealed small, non-foul smell-
ing lochia and no cervical motion or adnexal tenderness.
There was bulging noted in the posterior vaginal fornix.
The perineal repair was healing well, without induration
or erythema. Laboratory studies included a white blood
cell count of 21,000 cells per liter and a hemoglobin of
10.5 grams. The urinalysis was unremarkable, and sub-
sequent urine and blood cultures were negative. She was
HIV negative by antibody testing.
The patient underwent ultrasonography which re-
vealed a normal appearing postpartum uterus and adnexa.
A large amount of free fluid was seen in the abdomen
and pelvis. The appendix was not visualized. The CT
scan demonstrated multiple areas of loculated fluid
pockets (Figure 1). Again, the appendix was unable to
be visualized. The patient was empirically started on
cefoxitin in the emergency department. She was then
continued on metronidazole and ampicillin therapy upon
Figure 1. Admission computed tomography scan de-
monstrating multiple fluid collections in the peritoneal
cavity as denoted by asterisks.
R. Shabana et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 235-238
admission, and switched to Ampicillin-Sulbactam on the
fifth day of admission. A culdocentesis was performed
with drainage of 420 cc of purulent, foul-smelling fluid.
Cultures yielded Streptococcus anginosus and Prevotella
species. After surgery and interventional radiology con-
sultations, three indwelling 10-French pigtail catheters
were placed transabdominally at sites thought to contain
the largest fluid collections by CT imaging . Over 200 cc
of purulent fluid were initially collected at each of these
drainage sites, with steadily diminishing amounts subse-
quently. Aerobic and anaerobic cultures were negative
from all of these aspirates. At the drainage sites, abscess
resolution was noted later in the hospital course, while
other collections were re-demonstrated on CT imaging
(Figure 2). Throughout this time, the patient remained
stable, with improving symptomatology. Occasional low
grade temperature elevations were noted, without a newly
identified source. On hospital day 15, the previously
noted umbilical hernia became tender to palpation with
spontaneous drainage of purulent material similar to that
noted above. An associated fluid collection measuring
2.6 cm × 3.4 cm was identified. Cultures were again
negative. The patient was taken to the operating room
fordrainage of this collection an d umbilical h ernia repair.
The collection was drained, copiously irrigated with nor-
mal saline solution, and the fascial umbilical defect was
repaired with the skin left open. On hospital day 20, the
patient continued to be afebrile, was tolerating diet and
showed resolution of her abdominal pain. She was dis-
charged home on broad spectrum oral antibiotic therapy
with drains remaining in place. One week later, at her
Figure 2. Hospital day 13 computed tomography
scan after placement of drainage catheters. Reso-
lution of right and left lower quadrant collections
visualized. A discrete fluid collection within the
mesenteric space is noted (*).
scheduled follow up office visit, the patient had no
complaints and drains were removed.
Streptococcus anginosus group, also known as S. milleri,
are a gram positive cocci with known commensal colo-
nization of the mouth, nasopharynx, gastrointestinal tract,
and lower genital tract, with isolation rates ranging from
15% - 30% [1,2 ]. This group consists of three species: S.
anginosus, S. constellatus, and S. intermedius, and se-
veral subspecies [3]. Though all members of the Strep-
tococcus anginosus group share common phenotypic
characteristics, confusion surrounding serologic and he-
molytic characterization persists. Currently proposed me-
thods for identification of the Streptococcus anginosus
group, to the species level in particular, are time con-
suming and not routinely done in clinical practice. This
has lead to incomplete or misidentification of this gro up,
often as S. viridans organisms, which have different pre-
dilection and resistance patterns [4]. This is of significant
concern, in that the lack of recognition can lead to mis-
management of patients with life-threatening conditions.
The unique characteristic of the S. anginosus group,
distinguishing it from other streptococci, is its role in
pyogenic infections and its strong association with ab-
scess formation. S. anginosus produces deep-seated ab-
scesses in a frequency double that of the remainder of the
S. viridians group [5]. Serious underlying disease, such
as immunodeficiency, malignancy, and diabetes, as well
as, recent surgical intervention are predisposing factors
in 33% - 76% of S. anginosus infections [1]. Trauma to
the mucosal barrier and intra-abdominal infections, in-
cluding appendicitis and cholecystitis, were noted incit-
ing foci, although abscess formation may occur without
an obvious source [5-7].
Few reports of S. anginosus group infections are iden-
tified in a healthy obstetric and gynecologic patient po-
pulation. Isolated cases of wound infection, pelvic ab-
scesses, labial abscesses, and tuboovarian abscesses have
been previously described [1,8]. Of interest, three cases
of epidural abscesses have been reported in obstetric
patients, of which one was at 20 weeks of gestation, oc-
curring as a spontane ous event with out catheterization or
other invasive procedures. This case is of particular in-
terest due to the patient’s lack of predisposing conditions
and quick clinical deterioration [9]. The other two cases
involved young healthy women after spontaneous vagi-
nal deliveries with epidural catheter placement for anal-
gesia. Both underwent laminectomy and treatment with
antibiotics [8]. Th ere have also been limited case reports
of neonatal sepsis involving this organism with the pre-
sumption of vertical transmission from a colonized mother
[10]. S. anginosus may also play a role in causing septic
Copyright © 2012 SciRes. OPEN ACCESS
R. Shabana et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 235-238 237
abortions via ascending infection [11].
The case presented is of particular interest for several
reasons including the lack of obvious inciting cause, the
disparity between the patient’s eventually recognized
disease state and her presenting symptomatology, and the
choice of management. Treatment with systemic antibi-
otics and serial interventional radiology-directed drain-
age versus early surgical exploration remains controver-
sial. It has been noted in previous studies, that the ma-
jority of infectious S. anginosus cases originate from
skin/soft tissue or intraabdominal sources. Of 186 cases
of S. anginosus noted in a retrospective study, 64 had
skin/soft tissue manifestations and 41 had intraabdominal
manifestations. These in cluded liver abscess, cho langitis,
peritonitis, pancreatic abscess, subphrenic abscess, and
most commonly appendicitis, the source in 23 of the 41
cases [1]. Another study detailing 33 cases of S. angino-
sus and bacteremia found the majority were due to in-
traabdominal sources [7]. The inciting factors in these
cases included cholecystitis/cholangitis (18%) and ap-
pendicitis (12%) [7]. Given our patient’s extensive in-
traabdominal disease process, appendicitis was considered
a possible inciting focus. The patient underwent several
imaging procedures, including ultrasonography and se-
rial CT scanning, none of which allowed visualization of
the appendix. Though not visualized, there was also no
noted area of increased inflammation surrounding the
area of the appendix to suggest appendicitis. Of note, S.
anginosus is a commensal organism of the appendix and
was isolated from a quarter of normal-appearing appen-
dices, not in the setting of appendicitis [12]. Lastly, re-
garding a source of the infection, it should be recalled
that the patient had a small perineal laceration repaired in
an uncomplicated manner at the time of delivery. As pre-
viously noted, S. anginosus species are known to colo-
nize the lower female genital tract. Therefore, trauma to
this mucosal barrier may have been the site for entrance
of the pathogen. Our patient did not have any signs of in-
flammation, induration or purulence at the laceration site
upon subsequent presen tation to the hospital. Of interest,
certain S. anginosus biotypes have a specific affinity for
the vaginal mucosa. They are identified by the fact they
produce acid from raffinose and melibiose in the labora-
tory. Unfortunately our clinical specimen was not tested
with these substrates to help better define the source of
the organism.
A final point of interest in this case is the manage ment
of multiple intra-abdominal abscesses with percutaneous
drainage instead of surgical intervention. On presentatio n
the patient had significant abdominal tenderness, but
lacked other gastrointestinal symptoms. She was tolerat-
ing a regular diet and complained of only mildly de-
creased appetite. She was afebrile and hemodynamically
stable. Also, at the time of presentation, the patient had
been symptomatic for seven days, making surgical inter-
vention a potentially more complicated approach. Given
the noted clinical findings and the apparent amenability
of the fluid collections to drainage, the decision was
made to proceed wit h percutaneous drai na ge.
On review, there are several studies detailing the use
of radiology guided percutaneous drainage catheters for
intraabdominal abscesses and success rates comparable
to that of open intervention, with overall success rates
between 33% and 100% [13]. Three studies were re-
viewed detailing the management of intraabdominal ab-
scesses, leading to similar conclusions that percutaneous
drainage had a higher success rate determined by abscess
and sepsis resolution, and lower rates of complications,
when compared to operative intervention [14-16]. It
should be noted that second attempts at percutaneous
drainage were required in a significant number of pa-
tients described in the above studies and that the duration
of drain management ranged from 6 to 60 days. Our pa-
tient underwent a total of five drainage procedures and
three drainage catheter placement procedures, which
resulted in resolution of the fluid collections. Common
adverse events described with catheter management in-
cluded drains falling out or becoming clogged or dam-
aged, cellulitis at the drain site, and less commonly fis-
tula formation, bleeding, need for re-hospitalization, and
inability to place the drain.
Recognized limitations in the evaluation of this case
include the initiation of antibiotics prior to obtaining
cultures and the polymicrobial nature of the infection.
Intravenous antibiotic therapy was initiated prior to the
culdocentesis procedure from which the S. anginosus
cultures were obtained. This may have limited culture
results, suppressing growth of other involved pathogens.
Prevotella species was also isolated from the culdocente-
sis specimen. Its ability to cause abscesses and bactere-
mia is well documented, particularly in the mouth fol-
lowing invasive proc edures. Since both S. anginosus and
Prevotella both can colonize the oral cavity, a more care-
ful assessment of the patient’s teeth and mouth would
have been helpful despite there being no presenting sym-
ptomatology related to these structures. With regard to
antibiotic selection , the initial empiric use of broad spec-
trum antibiotics is justifiable given the presenting cir-
cumstances. Later, culture-based identification of the
causative pathogens would have allowed for therapeutic
modifications in the event of a suboptimal response, or if
microbial resistance was identified. Fortunately, S. angi-
nosus is sensitive to a wide variety of Gram-positive fo-
cused antimicrobial agents.
In summary, this case report details an unusual viru-
lent infection presenting in an otherwise young healthy
postpartum patient caused by S. anginosus. Because of
the pathologic potential for this organism, it highlights
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R. Shabana et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 235-238
Copyright © 2012 SciRes. OPEN ACCESS
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