Journal of Clinical Studies & Medical Case Reports Category: Medical Type: Case Report

Streptococcus Pseudoporcinus and Cardiac Implantable Electronic Device: Do We Need To Worry?? A Case Report.

Anthoula Plevritaki1*, Stelios Zervakis1, Alexandros Patrianakos1, Nikoleta Bizymi2, Nikolaos Kapsoritakis3, Eleftherios Kallergis1 and Prof Georgios Kochiadakis1
1 Cardiology department, University Hospital of Heraklion, Heraklion, Greece
2 Department of internal medicine, University Hospital of Heraklion, Heraklion, Greece
3 Department of nuclear medicine, School of Medicine, University of Crete, School of Medicine, University of Crete, Greece

*Corresponding Author(s):
Anthoula Plevritaki
Cardiology Department, University Hospital Of Heraklion, Heraklion, Greece

Received Date: Mar 13, 2024
Accepted Date: Mar 26, 2024
Published Date: Apr 02, 2024


Streptococcus pseudoporcinus was first recognized as a colonizer of the female genital tract but upcoming cases with no genitourinary infections have been reported since then. Here we report a case of an 81-year old male with a recently implanted cardiac device that was diagnosed with infective endocarditis caused by S. pseudoporcinus.


Bacteremia; β-hemolytic Streptococcus; Cardiac implantable device; Endocarditis; Hardware removal; Radiolabeled leucocyte scintigraphy; Streptococcus pseudoporcinusv


CIED: Cardiac Implantable Electronic Device 

IE: Infective Endocarditis 

CDRIE: Infective Endocarditis related to Cardiac Device 

ECG: Electrocardiography 

AVB: Atrioventricular block 

RBBB: Right bundle branch block 

TTE: Transthoracic echocardiogram

TEE: Transesophageal echocardiogram

History of Presentation

An 81-year-old gentleman presented with a 2-day history of fevers and chills. On admission, he was febrile, with a body temperature of 37.6°C, tachypneic (respiratory rate: 30 breaths/minute) with 97% oxygen saturation on room air, and hemodynamically stable. 

ECG showed sinus rhythm at 65 beats/minute, 1st degree AVB and RBBB. His physical examination was unremarkable, except for mild, diffuse abdominal tenderness on palpation. 

White blood cells count was 11,700 cells/μl (normal range: 3.8-10.5 cells/μl) with 73.4% neutrophils, hemoglobin was 9.4g/dl (14-18 g/dl), platelets were 96,000 K/μl (150-450), erythrocyte sediment rate was 107 mm/hr and C-reactive protein was 8.66 mg/dl ( < 0.5). Creatinine was 1.91 mg/dl (0.72-1.18mg/dl) and urea 66 mg/dl (17- 43 mg/dl). Urinalysis demonstrated proteinuria and increased RBCs.

Past Medical History

His medical history included hypertension, hyperlipidemia, cholecystectomy, past exposure to asbestos, Hodgkin lymphoma, portal hypertension with hepato/splenomegaly, angiectasias, colon polyps, and a recent 2-months-old  pacemaker implantation due to 3rd degree of AVB. 

Medications included ASA 100mg, bisoprolol 2,5mg, ramipril 5mg and acetaminophen as needed.

Differential diagnosis

His presentation was suspicious for abdominal infection. Non-infectious syndromes such as inflammatory bowel diseases, ischemic colitis, and malignancies can also present with fever and diffuse abdominal pain, though.


His chest and abdomen radiography were unremarkable. Ultra-sound and Computed tomography of the abdomen did not reveal relevant abnormal findings. Blood cultures were obtained while the patient was febrile and empiric antibiotic treatment was initiated. 

Blood cultures were soon reported to contain Gram-positive cocci in chains. 

A TTE demonstrated a normal ejection fraction with mild aortic stenosis and regurgitation and no evidence of valvular or lead vegetation. A TEE did not reveal signs of cardiac infection either (Figure 1).

 Figure 1: Tranesophageal Echocardiogram. Transesophageal echocardiogram did not reveal any vegetation on valves or pacer’s leads. 

Vascular and immunological phenomena were investigated and fundoscopy revealed a Roth spot in the left eye. 

Due to his recent cardiac device implantation, a radiolabelled leucocyte scintigraphy was performed, which was positive for lead infection (Figure 2).

 Figure 2: Radiolabelled Leucocyte Scintigraphy. 99mTc-HMPAO-WBC scintigraphy revealed the presence of CIED-associated infection. 

Streptococcus pseudoporcinus was later identified in three separate blood cultures.


According to the existing guidelines, our patient met the modified Duke’s criteria for definitive endocarditis, one major (endocardial involvement) and three minor criteria (fever, Roth spot, and positive blood cultures with an organism not typically associated with endocarditis). The patient received 2gr intravenous ceftriaxone daily in accordance with the antimicrobial susceptibility testing. 

Repeat blood cultures remained negative, and complete hardware removal (device and transvenous lead extraction) was performed after a prolonged (4-week) antibiotic therapy. Subsequent blood cultures along with hardware cultures were negative. 

Optimal timing for reimplatantion of a new cardiac device was under consideration since there is a lack of experience regarding appropriate management of such infections. During his hospitalization, he experienced a new unprovoked episode of symptomatic 3rd degree AVB that was initially treated with isoproterenol. 

Eventually, device reimplatantion was performed after 20days of hardware free interval and after 1-month antibiotic therapy completion.


Streptococcus pseudoporcinus is a β-hemolytic Streptococcus first isolated from female genito-urinary tract in 2006; it can be CAMP- and Lancefield group B-positive and therefore can be misidentified as Streptococcus agalactiae. However S. agalactiae has a narrow zone of beta-hemolysis, is hippurate hydrolysis positive, is bile esculin hydrolysis negative, and does not produce acid from mannitol or sorbitol, unlike S. pseudoporcinus [1]. 

It was initially considered a colonizer of the female genital tract and cases of infection in men were associated with sexual activity [1-3]. 

First recordings demonstrated S.pseudoporcinus as an emerging pathogen for adverse maternal or neonatal outcomes in pregnancy [3-4]. Additionally, it has been reported as the virulent factor of soft tissue infections [1,5,15] or for more invasive infections, for instance bacteremia/infective endocarditis [6-9,13,15] and peritonitis [9]. In fact, 5 cases of S. pseudoporcinus related endocarditis have been identified through a thorough literature review [5-8], all involving native valves. No cardiac or other prosthetic device infection has been reported in the existing literature until now (Table 1). 

Year of report


Patient Age(yrs)/Gender

Type of Infection

Site of isolation

Antibiotic Regimen



Mahlen, Clarridge III

33 M

Thumb infection

Wound purulence culture

10d cephalexin



Fang, Gandhi

77 M

Subacute mitral valve endocarditis

Blood cultures


Unknown (Transferred to other hospital for valve replacement)


Gullet et al

29 F

Pregnancy complications/slow fetal growth/Preeclampsia

Vaginorectal culture




Sawamura et al

94 F

Cellulitis of left lower extremity

Wound purulence culture

Cefepime+Vancomycin due to multi drug resistance



Pierce et al

41 F

Singleton fetal demise/Acute necrotizing chorioamnionitis+acute umbilical vasculitis

Urine, placenta, endometrium, 2 blood sets

Ampicillin+gentamicin->D3 amoxicillin




35 M

Aortic+mitral valve endocarditis/stroke_brain infracts

2 blood sets




Hai et al

40 M

Aortic valve infective endocarditis

3 blood sets

Cefepime 6gr+Ofloxacin 400mg

Recovered+aortic valve replacement


Akagi et al

40 M

Pulmonary valve (CCTGA) encocarditis+ IgA vasculitis+septic pulmonary emboli

2 blood sets


Recoveredtransferred to the initial hospital


Khan et al

81 M

Cellulitis of right lower extremity /Aortic+mitral valve endocarditis

Blood sets

Ceftriaxone 2gr changed to Vancomycin



Khan et al

72 F


Lung tissue, pleural fluid

Ceftriaxone 1gr changed to Ertapenem 1gr (coinfection)



Gupta et al

43 M


Blood sets

Ceftriaxone 2gr



Vergadi et al

9 M

Cellulitis of right lower extremity/Bacteremia

Blood sets

Ceftriaxone+Vancomycin->Clindamycin+Vancomycin 14d

Initially recovered-Cellulitis relapsed – discharged with 3-mo chemoprophylaxis


Liatsos et al

56 M

Spontaneous bacterial peritonitis (SBP) +bacteremia

Blood+ascitic fluid cultures

Meropenem 3gr+Daptomycin 350mg



Russo et al

45days infant

Relapsing cervical lymphadenitis

 Blood cultures

Ceftriaxone and oxacillin changed to ampicillin, followed by oral amoxicillin

Initially clinical improvement-disharged- cervical lymphadenitis. relapsed – workup for immunodeficiency- CD4 levels below 3rd percentile


Venincasa et al

59 F

Endophthalmitis – 3ws after a bilateral upper and lower blepharoplasty

Vitreous culture

Intravitreal injection of vancomycin and ceftazidime

Postoperative vision improved to 5/200 but was limited by a full-thickness macular hole.


Birlutiu et al

63 M

Endocarditis / Mastocytosis and Spondylodiscitis

Blood sets

Ceftriaxone 2g +Vancomycin 2g

Ceftriaxone for up to 4wks, levofloxacin 750 mg/d at discharge for 2 mo for spondylodiscitis


Dong, Tian


Orbital cellulitis -Corneal perforation

Pus culture


aggressive anti-infection+surgical treatment


Papapanagiotou et al

67 M

Bacteremia - soft tissue infection of left lower limb

2 Blood sets

Ceftriaxone 2gr (2 weeks)



Plevritaki et al

81 M

Endocarditis due to Cardiac Implantable Electronic Device Infection

3 Blood sets

Ceftriaxone 2gr

Recovered-New device was implanted

Table 1: Review of cases in the literature. 

Given the great similarities with Group B Streptococcus (Streptococcus agalactiae) [1] one could suppose a similar epidemiological and clinical behavior of both. Thus, they could represent an important cause of invasive infections in high-risk populations, especially in pregnant women, neonates, and the elderly and in individuals with underlying medical conditions such as diabetes, cirrhosis and cancer. 

Although Streptococcus species are commonly associated with endocarditis, this is the first known report of Streptococcus pseudoporcinus causing infective endocarditis related to cardiac device. 

S. pseudoporcinus can been isolated from human rectum, upper respiratory and genital tracts [3,5]. The definitive source of our patient’s S. pseudoporcinus is unclear. We postulate that it may have originated via gastrointestinal colonization and subsequent bacteremia due to his known angiectasias and splenomegaly. 

Last but not least, according to ESC guidelines, clinical presentation of CDRIE is frequently ambiguous and echocardiography and blood cultures are the cornerstones of diagnosis. A normal TTE does not rule out CDRIE and high suspicion is needed in the presence of unexplained fever in a patient with a CIED, whereas additive tools may be needed, such as radiolabelled leucocyte scintigraphy and 18F-FDG PET/CT scanning [10].


His postoperative course was uneventful. A 3-month overall antibiotic therapy was completed without any adverse concerns.


This is the first reported case of Streptococcus pseudoporcinus causing Infective Endocarditis related to Cardiac Device. 

Knowledge is limited regarding these recently differentiated novel species, and thus, reporting of previously unknown S.pseudoporcinus infection manifestations is of utmost importance. Accordingly, the present report extends current knowledge regarding the ability of S.pseudoporcinus to infect prosthetic materials and will, hopefully, raise the level of suspicion of cardiac or other prosthetic device infection in patients with persistent bacteremia. Moreover, given the lack of relevant experience and the successful outcome of the applied management course, this case could be used as a management/treatment guide, until consensus for such cases has been reached.

Learning Objectives

  1. To recognize Infective Endocarditis related to Cardiac Device and to raise the level of suspicion for IE in patients with a CIED and unexplained fever. 
  1. To understand that normal echographic examination does not rule out CDRIE and additive tools may be needed (radiolabelled leucocyte scintigraphy, 18F-FDG PET/CT scanning). 
  1. To discuss how bacteremia by an uncommon bacterium, Streptococcus pseudoporcinus can cause Infective Endocarditis related to Cardiac Device.


The authors have nothing to disclose.


No funding.


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Citation: Plevritaki A, Zervakis S, Patrianakos A, Bizymi N, Kapsoritakis N, et al. (2024) Streptococcus Pseudoporcinus and Cardiac Implantable Electronic Device: Do We Need To Worry?? A Case Report. J Clin Stud Med Case Rep 11:229

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