Bacteremia from Streptococcus constellatus revealing a Gastro-Intestinal Stromal Tumor

Bacteremia from Streptococcus constellatus revealing a Gastro-Intestinal Stromal Tumor | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Bacteremia from Streptococcus constellatus revealing a Gastro-Intestinal Stromal Tumor Salvatore Chessa, Elena Belfiori, Giulia Mandis, Enrico Urru, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3478448/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Jan, 2024 Read the published version in Gut Pathogens → Version 1 posted 9 You are reading this latest preprint version Abstract Background . Pyogenic Liver Abscesses (PLA) are the most common type of visceral abscess. They generally develop in a context of biliary disease or hematogenous seeding, but a complete diagnostic work-up is always required in order not to miss other important causes, including above all malignancies of the gastro-intestinal tract. Case presentation . Herein, we report a particular case of a 80 years-old immunocompetent woman hospitalized for sepsis. At the end of the diagnostic process, Streptococcus constellatus ( Sc) was identified as the cause of sepsis, multiple PLA were found together with a previous unknown ileal malignancy. We speculated about a possible correlation among these three entities (i.e. sepsis from Sc , PLA and tumors). Conclusions . Detection of Streptococcus constellatus in blood should raise red flags in clinicians as aggressive clinical presentation are possible. Streptococcus constellatus bacteriemia pyogenic liver abscesses GIST Figures Figure 1 Figure 2 BACKGROUND Sc is usually part of the normal flora of mouth and gastro-intestinal tract, but aggressive presentations are possible. They mainly consist in abscesses formation and this can occur in association with malignancy [ 1 ]. CASE PRESENTATION An 80-year-old Caucasian woman, with a medical history of hypertensive heart disease, reached the emergency room (ER) because of a fever lasting 3 days occurring after dental treatment, and no other relevant symptoms. She also reported two hospitalizations over the previous year: one for anaemia and unexplained deep vein thrombosis of the right leg; the other one for bowel sub-occlusion. During these previous admissions, an abdominal CT scan detected the presence of a jejunal mass, described as a mixed (solid-liquid) roundish lesion (54x48 mm). The surgeon did not prescribe any additional diagnostic investigation of the mass. At the admission to the ER, the patient was febrile (38,5°C). No remarkable signs were observable at physical examination and chest X-ray was negative. Blood test showed leucocytosis (23.6 x 10 9 /L) with 84.4% neutrophils and increase of both CRP (88.2 mg/L, normal values – nv − 0.0–5.0) and procalcitonin (41.2 ng/ml, nv < 0.5). After blood sample was drawn for blood cultures, an empirical antibiotic therapy with piperacillin-tazobactam was initiated. Thereafter, the patient was transferred to our Internal Medicine Unit. On the 3rd day an hypoxemic respiratory failure occurred, despite no inflammation nor infective process was observable on CT scan. It was interpreted as the first manifestation of a probable incipient Multiple Organ Dysfunction Syndrome (MODS). Blood tests only slightly improved (14.3 x 10 9 /L leucocytes with 76% neutrophils, CRP 111.9 mg/L, and procalcitonin 1.8 ng/mL). On day 6th blood cultures showed the growth of Sc sensitive to teicoplanin. Teicoplanin was added to therapy and, after four days of treatment, produced a relevant benefit on respiratory signs and oxygen supplementation demand, as well as on laboratory test (further decrease of WBC to 11.3 x 10 9 /L leucocytes with 67% neutrophils, CRP 17.5 mg/L, and normalization of procalcitonin). Meanwhile, we searched for septic foci. Urine culture was negative. A CT scan of facial bones did not show any periodontal inflammation or pulpal infection, ruling out the oral cavity as the source of the bacteremia. Echocardiography excluded an infective endocarditis. An abdominal US revealed the presence of multiple hepatic roundish lesions (the greatest at SVIII: 55x42 mm) (Fig. 1 ). These lesions appeared as three multiloculated cystic lesions surrounded by pseudocapsules at contrast-enhanced CT scan, suggesting the diagnosis of pyogenic liver abscesses; they were in SIII-IV (4 cm), SV (4 cm) and SV-VIII (8 cm) (Fig. 2 ). Though the significant peripheral arterialization indicated they were “pure” abscesses, we also considered whether they hid underlying hepatic metastatic lesions eventually infected by SC. Therefore, we looked for possible primary neoplastic lesion. Breast examination did not reveal the presence of a palpable mass, and the CT done on day 3rd failed to identify any potential previous unknown thoracic cancer. A total colonscopy showed a normal mucosa. Lastly, we focused on the jejunal mass detected at the previous hospitalization. It was no longer observable as a roundish lesion at CT scan; now it appeared as an eccentric thickening (20x10 mm) of the same intestinal loop with some inner cystic areas. Whether the lesion was an abscessed intestinal loop, or a group of inflammed diverticula, or the less common Meckel’s diverticulum, the patient underwent a surgical excision of the jejunal mass. Pathology identified the lesion as a Gastrointestinal Stromal Tumour (GIST). Due to its location, size (30 mm) and mitotic index (25/20 HPF), it was considered as high-risk lesion and a chemotherapy with imatinib was then prescribed. DISCUSSION AND CONCLUSIONS The S. anginosus group (SGA) consists of three species of Gram positive, catalase negative cocci, named S. anginosus ( Sa ), S. intermedius ( Si ) and S. constellatus ( Sc ). They are nonmotile, facultative anaerobes which can exhibit different haemolytic patterns [ 2 ]. Although in general they are part of normal oral and gastrointestinal (GI) flora [ 3 ], they can acquire the capacity to give bacteremia and form abscesses. This could be due to the production of both enzymes such as hyaluronidase, which drives the haematogenous spreading in the organism, and of pyrogenic exotoxins such as intermedilysin, which could play a role in the abscesses formation [ 4 ]. Sc has been increasingly reported as potential determinant of suppurative infections in a variety of sites [ 5 – 7 ] which seem to be related to the primary location of the bacteria and the route of migration. So, liver abscesses are often associated to pathological processes of GI tract (according to venous drainage of this area), which, however, are not necessarily of malignant nature [ 8 , 9 ]. Blood transmission could also explain other aggressive manifestations related to Sc , for example intracranial infectious aneurysms following a pulpitis caused by Sc , which was later responsible for an infection in the cavernous sinus [ 10 ]. Infection of a metastatic lesion also represent a cause of liver abscesses. Though we ruled out the presence of most common primary colon cancer, eventually we diagnosed a GIST in the jejunum, which may have represented the source of Sc bacteremia and liver abscesses. Only few cases of such an association - Sc bacteremia, PLA and GIST - have been reported in the literature [ 11 – 15 ]. More frequently, literature highlighted a relation between SGA and other digestive tract tumours, as esophageal [ 16 ], gastric [ 17 , 18 ] and colorectal cancer [ 19 – 22 ], these last associated to PLA. In particular, Sasaki H et al. [ 16 , 18 ] reported cloning of Sa DNA fragments from surgical specimens of esophageal and gastric cancers, but not from lung, cervix and kidney ones. Zhou CB et al. [ 17 ] found an association between Sc as well as Sa and gastric cancer and suggested that fecal Sc and Sa (detected using quantitative PCR) may represent non-invasive accurate signatures for precancerous and early stages of this kind of tumour. The relationship between Sc , PLA and GIST as well as SGA, PLA and colorectal cancer seems similar to the well-described association between these two last entities and Streptococcus bovis [ 23 ] or – as more recent studies have suggested – Klebsiella pneumoniae [ 24 ] and even other members of the intestinal microbiota. Some authors consider such relations not causative. They think neoplastic growth can disrupt the integrity of gastro-intestinal barrier, creating a pathway for bacterial translocation and systemic spreading [ 25 ]. At the end of our diagnostic work-up, we found a correlation between Sc , invasive infections and the presence of a malignancy. Although not yet validate in literature, this relationship should prompt physicians to screen for upper and lower GI neoplasms in patients presenting with sepsis or pyogenic infections caused by Sc , as it could facilitate an appropriate and timely treatment. Further investigation is needed in the future in order to better understand a possible etiopathogenetic role of Sc in carcinogenic process or as a potential marker of a GI tumor. Abbreviations CRP C-reactive protein CT computed tomography ER Emergency Room GI gastro-intestinal GIST gastro-intestinal stromal tumor PLA Pyogenic Liver Abscess Sc Streptococcus constellatus SGA Streptococcus anginosus group US Ultrasound Declarations ETHICAL APPROVAL All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patient provided informed consent. The patient agreed her data – properly anonymized – to be used for scientific purposes. FUNDING The authors did not receive support from any organization for the submitted work. The authors have no relevant financial or non-financial interests to disclose that are relevant to the content of this article. AVAILABILITY OF DATA AND MATERIALS Not applicable. Acknowledgments S. Chessa, E. Belfiori and G. Mandis gratefully acknowledge the Autonomous Region of Sardinia (RAS) for the financial support of their specialist medical training in Internal Medicine. References Whiley RA, Beighton D, Winstanley TG, Fraser HY, Hardie JM. Streptococcus intermedius, S treptococcus constellatus and Streptococcus anginosus (the Streptococcus mileri group): association with different body sites and clinical infections. J Clin Microbiol 1992; 30: 243-4. Ruoff KL. Streptococcus anginosus (“Streptococcus milleri”): the unrecognized pathogen. Clin Microbiol Rev. 1988; 1: 102–108. Mejaro B, Edwardsson S. Streptococcus milleri (Guthof); an indigenous organism of the human oral cavity. Arch Oral Biol. 1975; 20: 757. Nagamune H, Whiley RA, Goto T, Inai Y, Maeda T, Hardie JM, Kourai H. Distribution of the intermedilysin gene among the anginosus group streptococci and correlation between intermedilysin production and deep-seated infection with Streptococcus intermedius. J Clin Microbiol. 2000; 38: 220. Clarridge JE, Attorri S, Musher DM, Hebert J, Dunbar S. Streptococcus intermedius , Streptococcus constellatus , and Streptococcus anginosus (“Streptococcus milleri Group”) are of different clinical importance and are not equally associated with abscess. Clinical Infectious Diseases. 2001; 32(10): 1511–1515. Brunink, E.M., Hoogervorst, L.A., Steentjes, K. et al. Osteomyelitis caused by Streptococcus intermedius in immunocompetent adults — a case report and systematic literature review.Eur J Clin Microbiol Infect Dis 42, 1055–1061 (2023). https://doi.org/10.1007/s10096-023-04640-7 . Chamat-Hedemand, S., Dahl, A., Hassager, C. et al. Streptococcal infective endocarditis: clinical features and outcomes according to species. Infection 51, 869–879 (2023). https://doi.org/10.1007/s15010-022-01929-1 . Akuzawa N, Hatori T, Kitahara Y, Kurabayashi M. Multiple liver abscesses and bacteremia caused by Streptococcus constellatus infection: a case report. Clinical Case Reports. 2017; 5(1): 69–74. Rossi, G., Nguyen, Y., Lafont, E. et al. Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses. Infection 50, 1205–1215 (2022). Zhang, L., Liu, P., Li, Y. et al. Rapid development of an intracranial infectious aneurysm secondary to Streptococcus constellatus infection. Intensive Care Med 49, 593–594 (2023). Matsutani T, Onda M, Miyashita M, Hao K, Yokoyama S, et al. Liver abscesses associated with stromal tumour of the stomach in a young woman. Eur J Gastroenterol Hepatol. 2001; 13: 1485–148. Kim BH, Lee JH, Baik du S, Yun SW, Kim JH, et al. A case of malignant gastrointestinal stromal tumor of ileum with liver abscess. Korean J Gastroenterol. 2007; 50: 393–397. Kumar A, Artifon E, Siegel C, Halwan B. Gastrointestinal stromal tumor in association with pyogenic liver abscess. Gastroenterol Hepatol. 2008; 4: 818–819. Kwon Y, Dang ND, Elmunzer BJ. Gastrointestinal stromal tumor complicated by Streptococcus milleri bacteremia and liver abscess. Eur. J. Gastroenterol. Hepatol. 2009; 21(7): 824–826. Gorelik M, Sabates B, Elkbuli A, Dunne T. Ileal GIST presenting with bacteremia and liver abscess: a case report and review of literature. Int J Surg Case Rep. 2018; 42: 261–265. doi: 10.1016/j.ijscr.2017.12.033 . Epub 2017 Dec 27. PMID: 29324374; PMCID: PMC5985260. Sasaki H, Ishizuka T, Muto M, Nezu M, Nakanishi Y, et al. Presence of Streptococcus anginosus DNA in esophageal cancer, dysplasia of esophagus, and gastric cancer. Cancer Res. 1998; 58(14): 2991–2995. Zhou CB, Pan SY, Jin P, Deng JW, Xue JH, Ma XY, et al. Fecal signatures of Streptococcus anginosus and Streptococcus constellatus for noninvasive screening and early warning of gastric cancer. Gastroenterology. 2022; 162(7): 1933–1947. Sasaki H, Hiroyasu I, Ishizuka T, Kogoma Y, Sugimura T, Terada M. Presence of Streptococcus DNA sequence in surgical specimens of gastric cancer. Jpn J Cancer Res. 1995; 86: 791–794. Rawla P, Vellipuram AR, Bandaru SS, Raj JP. Colon carcinoma presenting as Streptococcus anginosus bacteremia and liver abscess. Gastroenterol Res. 2017; 10(6): 376–379. Millichap JJ, McKendrick AI, Drelichman VS. Streptococcus intermedius liver abscesses and colon cancer: a case report. West Indian Med J. 2005; 54(5) 341–342. Masood U, Sharma A, Lowe D, Khan R, Manocha D. Colorectal cancer associated with Streptococcus anginosus bacteremia and liver abscesses. Gastroenterology. 2016; 10: 769–774. Tzur T, Liberman S, Felzenstein I, Cohen R, Rivkind AI, Almogy G. Liver abscesses caused by Streptococcus milleri : an uncommon presenting sign of silent colonic cancer. Isr Med Assoc J. 2003; 5(3): 206–207. Burnett-Hartman AN, Newcomb PA, Potter JD. Infectious agents and colorectal cancer: a review of Helicobacter pylori, Streptococcus bovis, JC virus, and human papillomavirus. Cancer Epidemiol Biomarkers Prev. 2008; 17: 2970. Kao WY, Hwang CY, Chang YT, et al. Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study. Aliment Pharmacol Ther. 2012; 36: 467. Kao WY, Hwang CY, Chang YT, et al. Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study. Aliment Pharmacol Ther. 2012; 36: 467. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Jan, 2024 Read the published version in Gut Pathogens → Version 1 posted Editorial decision: Revision requested 03 Dec, 2023 Reviews received at journal 03 Dec, 2023 Reviews received at journal 24 Nov, 2023 Reviewers agreed at journal 20 Nov, 2023 Reviewers agreed at journal 10 Nov, 2023 Reviewers invited by journal 27 Oct, 2023 Submission checks completed at journal 24 Oct, 2023 Editor assigned by journal 24 Oct, 2023 First submitted to journal 22 Oct, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3478448","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":242528737,"identity":"56a100b6-79cd-4431-9de0-89008bd4d41f","order_by":0,"name":"Salvatore Chessa","email":"","orcid":"","institution":"University Hospital (AOU) Cagliari – Policlinico Universitario Monserrato","correspondingAuthor":false,"prefix":"","firstName":"Salvatore","middleName":"","lastName":"Chessa","suffix":""},{"id":242528738,"identity":"d9bf7642-d22a-4059-aa47-c367459120e6","order_by":1,"name":"Elena Belfiori","email":"","orcid":"","institution":"University 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18:59:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3478448/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3478448/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13099-023-00593-6","type":"published","date":"2024-01-04T15:01:49+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":45376169,"identity":"1456f810-68f5-4a6a-8be8-a6b5d6d47e37","added_by":"auto","created_at":"2023-10-28 17:27:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":188788,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAbdominal US showing the greatest of three roundish hepatic lesions with microcalcifications and colliquated areas inside.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3478448/v1/80302a379ab1edfb25fb44e1.png"},{"id":45377226,"identity":"aee7b3b6-22c9-4395-9590-3b790e46207b","added_by":"auto","created_at":"2023-10-28 17:35:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":242847,"visible":true,"origin":"","legend":"\u003cp\u003eLegend is not included with this version\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3478448/v1/1783646425989fce6c09e4f6.png"},{"id":49315730,"identity":"7b89070a-c1ff-4146-9787-ba6e3e5737aa","added_by":"auto","created_at":"2024-01-08 15:10:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":647576,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3478448/v1/560b7c2c-b0e2-48df-8961-0170a609fa53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bacteremia from Streptococcus constellatus revealing a Gastro-Intestinal Stromal Tumor","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003e \u003cem\u003eSc\u003c/em\u003e is usually part of the normal flora of mouth and gastro-intestinal tract, but aggressive presentations are possible. They mainly consist in abscesses formation and this can occur in association with malignancy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eAn 80-year-old Caucasian woman, with a medical history of hypertensive heart disease, reached the emergency room (ER) because of a fever lasting 3 days occurring after dental treatment, and no other relevant symptoms.\u003c/p\u003e \u003cp\u003eShe also reported two hospitalizations over the previous year: one for anaemia and unexplained deep vein thrombosis of the right leg; the other one for bowel sub-occlusion. During these previous admissions, an abdominal CT scan detected the presence of a jejunal mass, described as a mixed (solid-liquid) roundish lesion (54x48 mm). The surgeon did not prescribe any additional diagnostic investigation of the mass.\u003c/p\u003e \u003cp\u003eAt the admission to the ER, the patient was febrile (38,5\u0026deg;C). No remarkable signs were observable at physical examination and chest X-ray was negative. Blood test showed leucocytosis (23.6 x 10\u003csup\u003e9\u003c/sup\u003e/L) with 84.4% neutrophils and increase of both CRP (88.2 mg/L, normal values \u0026ndash; nv \u0026minus;\u0026thinsp;0.0\u0026ndash;5.0) and procalcitonin (41.2 ng/ml, nv\u0026thinsp;\u0026lt;\u0026thinsp;0.5). After blood sample was drawn for blood cultures, an empirical antibiotic therapy with piperacillin-tazobactam was initiated.\u003c/p\u003e \u003cp\u003eThereafter, the patient was transferred to our Internal Medicine Unit.\u003c/p\u003e \u003cp\u003eOn the 3rd day an hypoxemic respiratory failure occurred, despite no inflammation nor infective process was observable on CT scan. It was interpreted as the first manifestation of a probable incipient Multiple Organ Dysfunction Syndrome (MODS). Blood tests only slightly improved (14.3 x 10\u003csup\u003e9\u003c/sup\u003e/L leucocytes with 76% neutrophils, CRP 111.9 mg/L, and procalcitonin 1.8 ng/mL).\u003c/p\u003e \u003cp\u003eOn day 6th blood cultures showed the growth of \u003cem\u003eSc\u003c/em\u003e sensitive to teicoplanin. Teicoplanin was added to therapy and, after four days of treatment, produced a relevant benefit on respiratory signs and oxygen supplementation demand, as well as on laboratory test (further decrease of WBC to 11.3 x 10\u003csup\u003e9\u003c/sup\u003e/L leucocytes with 67% neutrophils, CRP 17.5 mg/L, and normalization of procalcitonin).\u003c/p\u003e \u003cp\u003eMeanwhile, we searched for septic foci. Urine culture was negative. A CT scan of facial bones did not show any periodontal inflammation or pulpal infection, ruling out the oral cavity as the source of the bacteremia. Echocardiography excluded an infective endocarditis. An abdominal US revealed the presence of multiple hepatic roundish lesions (the greatest at SVIII: 55x42 mm) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThese lesions appeared as three multiloculated cystic lesions surrounded by pseudocapsules at contrast-enhanced CT scan, suggesting the diagnosis of pyogenic liver abscesses; they were in SIII-IV (4 cm), SV (4 cm) and SV-VIII (8 cm) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThough the significant peripheral arterialization indicated they were \u0026ldquo;pure\u0026rdquo; abscesses, we also considered whether they hid underlying hepatic metastatic lesions eventually infected by SC. Therefore, we looked for possible primary neoplastic lesion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBreast examination did not reveal the presence of a palpable mass, and the CT done on day 3rd failed to identify any potential previous unknown thoracic cancer.\u003c/p\u003e \u003cp\u003eA total colonscopy showed a normal mucosa.\u003c/p\u003e \u003cp\u003eLastly, we focused on the jejunal mass detected at the previous hospitalization. It was no longer observable as a roundish lesion at CT scan; now it appeared as an eccentric thickening (20x10 mm) of the same intestinal loop with some inner cystic areas. Whether the lesion was an abscessed intestinal loop, or a group of inflammed diverticula, or the less common Meckel\u0026rsquo;s diverticulum, the patient underwent a surgical excision of the jejunal mass. Pathology identified the lesion as a Gastrointestinal Stromal Tumour (GIST). Due to its location, size (30 mm) and mitotic index (25/20 HPF), it was considered as high-risk lesion and a chemotherapy with imatinib was then prescribed.\u003c/p\u003e"},{"header":"DISCUSSION AND CONCLUSIONS","content":"\u003cp\u003eThe \u003cem\u003eS. anginosus\u003c/em\u003e group (SGA) consists of three species of Gram positive, catalase negative cocci, named \u003cem\u003eS. anginosus\u003c/em\u003e (\u003cem\u003eSa\u003c/em\u003e), \u003cem\u003eS. intermedius\u003c/em\u003e (\u003cem\u003eSi\u003c/em\u003e) and \u003cem\u003eS. constellatus\u003c/em\u003e (\u003cem\u003eSc\u003c/em\u003e). They are nonmotile, facultative anaerobes which can exhibit different haemolytic patterns [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough in general they are part of normal oral and gastrointestinal (GI) flora [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], they can acquire the capacity to give bacteremia and form abscesses. This could be due to the production of both enzymes such as hyaluronidase, which drives the haematogenous spreading in the organism, and of pyrogenic exotoxins such as intermedilysin, which could play a role in the abscesses formation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eSc\u003c/em\u003e has been increasingly reported as potential determinant of suppurative infections in a variety of sites [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] which seem to be related to the primary location of the bacteria and the route of migration. So, liver abscesses are often associated to pathological processes of GI tract (according to venous drainage of this area), which, however, are not necessarily of malignant nature [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Blood transmission could also explain other aggressive manifestations related to \u003cem\u003eSc\u003c/em\u003e, for example intracranial infectious aneurysms following a pulpitis caused by \u003cem\u003eSc\u003c/em\u003e, which was later responsible for an infection in the cavernous sinus [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInfection of a metastatic lesion also represent a cause of liver abscesses. Though we ruled out the presence of most common primary colon cancer, eventually we diagnosed a GIST in the jejunum, which may have represented the source of \u003cem\u003eSc\u003c/em\u003e bacteremia and liver abscesses.\u003c/p\u003e \u003cp\u003eOnly few cases of such an association - \u003cem\u003eSc\u003c/em\u003e bacteremia, PLA and GIST - have been reported in the literature [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore frequently, literature highlighted a relation between SGA and other digestive tract tumours, as esophageal [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], gastric [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and colorectal cancer [\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], these last associated to PLA.\u003c/p\u003e \u003cp\u003eIn particular, Sasaki H \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported cloning of \u003cem\u003eSa\u003c/em\u003e DNA fragments from surgical specimens of esophageal and gastric cancers, but not from lung, cervix and kidney ones. Zhou CB \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found an association between \u003cem\u003eSc\u003c/em\u003e as well as \u003cem\u003eSa\u003c/em\u003e and gastric cancer and suggested that fecal \u003cem\u003eSc\u003c/em\u003e and \u003cem\u003eSa\u003c/em\u003e (detected using quantitative PCR) may represent non-invasive accurate signatures for precancerous and early stages of this kind of tumour.\u003c/p\u003e \u003cp\u003eThe relationship between \u003cem\u003eSc\u003c/em\u003e, PLA and GIST as well as SGA, PLA and colorectal cancer seems similar to the well-described association between these two last entities and \u003cem\u003eStreptococcus bovis\u003c/em\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] or \u0026ndash; as more recent studies have suggested \u0026ndash; \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and even other members of the intestinal microbiota. Some authors consider such relations not causative. They think neoplastic growth can disrupt the integrity of gastro-intestinal barrier, creating a pathway for bacterial translocation and systemic spreading [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the end of our diagnostic work-up, we found a correlation between \u003cem\u003eSc\u003c/em\u003e, invasive infections and the presence of a malignancy. Although not yet validate in literature, this relationship should prompt physicians to screen for upper and lower GI neoplasms in patients presenting with sepsis or pyogenic infections caused by \u003cem\u003eSc\u003c/em\u003e, as it could facilitate an appropriate and timely treatment.\u003c/p\u003e \u003cp\u003eFurther investigation is needed in the future in order to better understand a possible etiopathogenetic role of \u003cem\u003eSc\u003c/em\u003e in carcinogenic process or as a potential marker of a GI tumor.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Room\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastro-intestinal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGIST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egastro-intestinal stromal tumor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePyogenic Liver Abscess\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSc\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStreptococcus constellatus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSGA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStreptococcus anginosus group\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eETHICAL APPROVAL\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatient provided informed consent. The patient agreed her data \u0026ndash; properly anonymized \u0026ndash; to be used for scientific purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFUNDING\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose \u0026nbsp;that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS. Chessa, E. Belfiori and G. Mandis gratefully acknowledge the Autonomous Region of Sardinia (RAS) for the financial support of their specialist medical training in Internal Medicine.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWhiley RA, Beighton D, Winstanley TG, Fraser HY, Hardie JM. Streptococcus intermedius, \u003cem\u003eS treptococcus constellatus\u003c/em\u003e and \u003cem\u003eStreptococcus anginosus\u003c/em\u003e (the \u003cem\u003eStreptococcus mileri\u003c/em\u003e group): association with different body sites and clinical infections. J Clin Microbiol 1992; 30: 243-4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRuoff KL. Streptococcus anginosus (\u0026ldquo;Streptococcus milleri\u0026rdquo;): the unrecognized pathogen. Clin Microbiol Rev. 1988; 1: 102\u0026ndash;108.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMejaro B, Edwardsson S. Streptococcus milleri (Guthof); an indigenous organism of the human oral cavity. Arch Oral Biol. 1975; 20: 757.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNagamune H, Whiley RA, Goto T, Inai Y, Maeda T, Hardie JM, Kourai H. Distribution of the intermedilysin gene among the anginosus group streptococci and correlation between intermedilysin production and deep-seated infection with Streptococcus intermedius. J Clin Microbiol. 2000; 38: 220.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eClarridge JE, Attorri S, Musher DM, Hebert J, Dunbar S. \u003cem\u003eStreptococcus intermedius\u003c/em\u003e, \u003cem\u003eStreptococcus constellatus\u003c/em\u003e, and \u003cem\u003eStreptococcus anginosus\u003c/em\u003e (\u0026ldquo;Streptococcus milleri Group\u0026rdquo;) are of different clinical importance and are not equally associated with abscess. Clinical Infectious Diseases. 2001; 32(10): 1511\u0026ndash;1515.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBrunink, E.M., Hoogervorst, L.A., Steentjes, K. \u003cem\u003eet al.\u003c/em\u003e Osteomyelitis caused by \u003cem\u003eStreptococcus intermedius\u003c/em\u003e in immunocompetent adults \u0026mdash; a case report and systematic literature review.Eur J Clin Microbiol Infect Dis 42, 1055\u0026ndash;1061 (2023). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10096-023-04640-7\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChamat-Hedemand, S., Dahl, A., Hassager, C. \u003cem\u003eet al.\u003c/em\u003e Streptococcal infective endocarditis: clinical features and outcomes according to species. Infection 51, 869\u0026ndash;879 (2023). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s15010-022-01929-1\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAkuzawa N, Hatori T, Kitahara Y, Kurabayashi M. Multiple liver abscesses and bacteremia caused by \u003cem\u003eStreptococcus constellatus\u003c/em\u003e infection: a case report. Clinical Case Reports. 2017; 5(1): 69\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRossi, G., Nguyen, Y., Lafont, E. \u003cem\u003eet al.\u003c/em\u003e Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses.\u003cem\u003eInfection\u003c/em\u003e 50, 1205\u0026ndash;1215 (2022).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhang, L., Liu, P., Li, Y. \u003cem\u003eet al.\u003c/em\u003e Rapid development of an intracranial infectious aneurysm secondary to \u003cem\u003eStreptococcus constellatus\u003c/em\u003e infection. Intensive Care Med 49, 593\u0026ndash;594 (2023).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMatsutani T, Onda M, Miyashita M, Hao K, Yokoyama S, et al. Liver abscesses associated with stromal tumour of the stomach in a young woman. Eur J Gastroenterol Hepatol. 2001; 13: 1485\u0026ndash;148.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKim BH, Lee JH, Baik du S, Yun SW, Kim JH, et al. A case of malignant gastrointestinal stromal tumor of ileum with liver abscess. Korean J Gastroenterol. 2007; 50: 393\u0026ndash;397.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKumar A, Artifon E, Siegel C, Halwan B. Gastrointestinal stromal tumor in association with pyogenic liver abscess. Gastroenterol Hepatol. 2008; 4: 818\u0026ndash;819.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKwon Y, Dang ND, Elmunzer BJ. Gastrointestinal stromal tumor complicated by Streptococcus milleri bacteremia and liver abscess. Eur. J. Gastroenterol. Hepatol. 2009; 21(7): 824\u0026ndash;826.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGorelik M, Sabates B, Elkbuli A, Dunne T. Ileal GIST presenting with bacteremia and liver abscess: a case report and review of literature. Int J Surg Case Rep. 2018; 42: 261\u0026ndash;265. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijscr.2017.12.033\u003c/span\u003e\u003c/span\u003e. Epub 2017 Dec 27. PMID: 29324374; PMCID: PMC5985260.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSasaki H, Ishizuka T, Muto M, Nezu M, Nakanishi Y, et al. Presence of \u003cem\u003eStreptococcus anginosus\u003c/em\u003e DNA in esophageal cancer, dysplasia of esophagus, and gastric cancer. Cancer Res. 1998; 58(14): 2991\u0026ndash;2995.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZhou CB, Pan SY, Jin P, Deng JW, Xue JH, Ma XY, et al. Fecal signatures of \u003cem\u003eStreptococcus anginosus\u003c/em\u003e and \u003cem\u003eStreptococcus constellatus\u003c/em\u003e for noninvasive screening and early warning of gastric cancer. Gastroenterology. 2022; 162(7): 1933\u0026ndash;1947.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSasaki H, Hiroyasu I, Ishizuka T, Kogoma Y, Sugimura T, Terada M. Presence of \u003cem\u003eStreptococcus\u003c/em\u003e DNA sequence in surgical specimens of gastric cancer. Jpn J Cancer Res. 1995; 86: 791\u0026ndash;794.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRawla P, Vellipuram AR, Bandaru SS, Raj JP. Colon carcinoma presenting as \u003cem\u003eStreptococcus anginosus\u003c/em\u003e bacteremia and liver abscess. Gastroenterol Res. 2017; 10(6): 376\u0026ndash;379.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMillichap JJ, McKendrick AI, Drelichman VS. \u003cem\u003eStreptococcus intermedius\u003c/em\u003e liver abscesses and colon cancer: a case report. West Indian Med J. 2005; 54(5) 341\u0026ndash;342.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMasood U, Sharma A, Lowe D, Khan R, Manocha D. Colorectal cancer associated with \u003cem\u003eStreptococcus anginosus\u003c/em\u003e bacteremia and liver abscesses. Gastroenterology. 2016; 10: 769\u0026ndash;774.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTzur T, Liberman S, Felzenstein I, Cohen R, Rivkind AI, Almogy G. Liver abscesses caused by \u003cem\u003eStreptococcus milleri\u003c/em\u003e: an uncommon presenting sign of silent colonic cancer. Isr Med Assoc J. 2003; 5(3): 206\u0026ndash;207.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBurnett-Hartman AN, Newcomb PA, Potter JD. Infectious agents and colorectal cancer: a review of Helicobacter pylori, Streptococcus bovis, JC virus, and human papillomavirus. Cancer Epidemiol Biomarkers Prev. 2008; 17: 2970.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKao WY, Hwang CY, Chang YT, et al. Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study. Aliment Pharmacol Ther. 2012; 36: 467.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKao WY, Hwang CY, Chang YT, et al. Cancer risk in patients with pyogenic liver abscess: a nationwide cohort study. Aliment Pharmacol Ther. 2012; 36: 467.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"gut-pathogens","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gutp","sideBox":"Learn more about [Gut Pathogens](http://gutpathogens.biomedcentral.com/)","snPcode":"13099","submissionUrl":"https://submission.nature.com/new-submission/13099/3","title":"Gut Pathogens","twitterHandle":"@GutPathogens","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Streptococcus constellatus, bacteriemia, pyogenic liver abscesses, GIST","lastPublishedDoi":"10.21203/rs.3.rs-3478448/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3478448/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/em\u003e. Pyogenic Liver Abscesses (PLA) are the most common type of visceral abscess. They generally develop in a context of biliary disease or hematogenous seeding, but a complete diagnostic work-up is always required in order not to miss other important causes, including above all malignancies of the gastro-intestinal tract.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/em\u003e. Herein, we report a particular case of a 80 years-old immunocompetent woman hospitalized for sepsis. At the end of the diagnostic process, \u003cem\u003eStreptococcus constellatus\u003c/em\u003e(\u003cem\u003eSc)\u003c/em\u003e was identified as the cause of sepsis, multiple PLA were found together with a previous unknown ileal malignancy. We speculated about a possible correlation among these three entities (i.e. sepsis from \u003cem\u003eSc\u003c/em\u003e, PLA and tumors).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/em\u003e. Detection of \u003cem\u003eStreptococcus constellatus\u003c/em\u003e in blood should raise red flags in clinicians as aggressive clinical presentation are possible.\u003c/p\u003e","manuscriptTitle":"Bacteremia from Streptococcus constellatus revealing a Gastro-Intestinal Stromal Tumor","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-28 17:27:43","doi":"10.21203/rs.3.rs-3478448/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-12-04T00:58:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-12-04T00:51:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-24T07:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2d84b0ab-db0c-4690-bfbc-72c559a9fe2d","date":"2023-11-20T10:36:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"03a7cd8d-eaa1-4d00-a0cf-74b50276b87b","date":"2023-11-10T10:26:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-27T23:15:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-24T14:28:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-24T14:28:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Gut Pathogens","date":"2023-10-22T18:46:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"gut-pathogens","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gutp","sideBox":"Learn more about [Gut Pathogens](http://gutpathogens.biomedcentral.com/)","snPcode":"13099","submissionUrl":"https://submission.nature.com/new-submission/13099/3","title":"Gut Pathogens","twitterHandle":"@GutPathogens","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0b8e67d8-8f35-4827-a801-05b5b908be85","owner":[],"postedDate":"October 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-08T15:06:53+00:00","versionOfRecord":{"articleIdentity":"rs-3478448","link":"https://doi.org/10.1186/s13099-023-00593-6","journal":{"identity":"gut-pathogens","isVorOnly":false,"title":"Gut Pathogens"},"publishedOn":"2024-01-04 15:01:49","publishedOnDateReadable":"January 4th, 2024"},"versionCreatedAt":"2023-10-28 17:27:43","video":"","vorDoi":"10.1186/s13099-023-00593-6","vorDoiUrl":"https://doi.org/10.1186/s13099-023-00593-6","workflowStages":[]},"version":"v1","identity":"rs-3478448","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3478448","identity":"rs-3478448","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}