USMLE® Step 1 style questions USMLE
A 45-year-old man with a history of systemic lupus erythematosus, end-stage kidney disease on dialysis, diabetes, and hypertension presents to the emergency department with a two day history of fever, chills, and dyspnea on exertion. The patient reports he receives dialysis 3 times/week and has not missed any of his scheduled appointments. He last received dialysis two days ago. Temperature is 38.7°C (101.6°F), pulse is 104/min, respirations are 24/min, blood pressure is 90/62 mmHg, and oxygen saturation is 90% on room air. On physical examination the patient is ill-appearing. There are erythematous lesions noted on the chest and arms bilaterally, as well as a fistula with a palpable thrill in the left arm without evidence of overlying erythema, discharge, or excoriation. A holosystolic murmur is appreciated at the lower left sternal border. Which of the following best describes the pathogenesis of this patient’s disease process?
Content Reviewers:Viviana Popa, MD
Contributors:Miguel Quintana, MD
The term “streptococcus viridans”, refers to five groups of Streptococci that include Streptococcus anginosus group, mitis group, sanguinis group, salivarius group, and finally the mutans group.
And each of these groups has approximately 30 species that can cause disease in humans.
So the more correct term would be “viridans streptococci”, to reflect that there’s more than one of them.
Generally speaking, viridans streptococci can’t be assigned to a Lancefield group based on their cell wall antigens.
However, in the Streptococcus anginosus group, some species can be assigned to Lancefield groups A, C, F or G.
Now, viridans streptococci have a thick peptidoglycan cell wall, which takes in purple dye when Gram stained - so they’re gram-positive bacteria.
They’re also catalase negative - which means they don’t produce an enzyme called catalase. Ok, now, when cultivated on a medium called blood agar, viridans streptococci colonies cause alpha hemolysis, also called green hemolysis, because they produce hydrogen peroxide, which partially oxidizes initially red hemoglobin in the blood agar to green methemoglobin.
One way to remember this is to think that 'viridans’ means ‘green’ in Latin.
Some species in the Streptococcus anginosus group, however, can also be beta-hemolytic or nonhemolytic.
These guys are special little snowflakes.
Now, other Streptococcus species, like Streptococcus pneumoniae, are also alpha hemolytic.
So, an optochin test is done to distinguish them.
That’s where an optochin-containing paper disc is placed on a plate of blood agar that has been inoculated with the bacteria.
On the flip side, viridans streptococci are optochin resistant - meaning there’s no inhibition of the growth around the optochin disc.
Another test that can be used to distinguish Strep viridans from Strep pneumoniae is the bile solubility test, which can be done in a test tube, or more commonly, by dripping drops of bile on bacterial colonies.
Strep pneumoniae is bile soluble, meaning that the bile salts will promote the lysis of the bacteria; whereas viridans streptococci are bile insoluble, or bile resistant.
Finally, viridans streptococci also lack the polysaccharide-based capsule typical of Streptococcus pneumoniae.
So, they live alongside their host without causing harm unless there’s a change in their environment.
Inside the mouth, viridans streptococci like Streptococcus mutans, and Streptococcus mitis adhere to tooth enamel with the help of a dextran polysaccharide, and aggregate, forming dental plaques which can lead to dental caries, dental caries, and gum disease.
In contrast, Streptococcus sanguinis promotes dental health by inhibiting the growth of Streptococcus mutans.
However, when dental work is done, like a tooth extraction, viridans streptococci can enter the bloodstream and cause bacteremia.
From there, they can make their way to the heart, where they may stick to a thrombus - an aggregate of platelets, red blood cells, and a mesh of cross-linked fibrin protein - on a damaged or prosthetic heart valve and cause subacute valve endocarditis.