When the Good Becomes the Bad: A Case of Lactobacillus rhamnosus Septicemia Unrelated to Probiotic Use

Introduction:Lactobacilli are gram positive, facultative anaerobic bacilli that live as commensals in the gastrointestinal and genitourinary tracts. They are promoted as probiotics. Although they are considered non-pathogenic, there are case reports of Lactobacillus-related serious infections in immunosuppressed hosts - mostly associated with probiotics use. We present a case of Lactobacillus septicemia unrelated to probiotic use. Case Description: A 64-year old male presented with complaints of jaundice and an unintentional 40 pounds weight loss. Physical exam revealed a cachectic male with whole-body jaundice and scleral icterus with epigastric tenderness. The patient and family denied any probiotic use. Laboratory tests suggested an obstructive jaundice. CT-abdomen revealed a mass in the head of the pancreas with intra and extra hepatic biliary dilatation. He underwent ERCP followed by percutaneous biliary drainage. His post-operative course was further complicated by sepsis due to fungemia. While on Micafungin (and having completed a course of Meropenem and Vancomycin, empirically for cholangitis), his sepsis remained unresolved. Repeat blood cultures grew Lactobacillus Rhamnosus (4 sets) with resistance to Vancomycin (MIC1:256). In view of multiple comorbidities and recent antibiotic use, he was treated with Daptomycin and repeat cultures after 72 hours were negative with improvement in his sepsis.Conclusions:It was hypothesized that the recent instrumentation along with the tumor eroding the vessels and ductal system of the pancreas resulted in the translocation of Lactobacillus into the bloodstream. This case recognizes Lactobacillus as a potential pathogen and that blood cultures with susceptibility testing are important in guiding treatment.