# A Rare Presentation of Cholangitis Associated With Invasive Streptococcus Pyogenes

## TL;DR

A rare case of cholangitis caused by invasive Streptococcus pyogenes is reported in a man with metastatic pancreatic cancer.

## Contribution

This paper presents a rare clinical case of cholangitis associated with invasive S. pyogenes infection.

## Key findings

- S. pyogenes was isolated from both blood and biliary fluid cultures in a patient with cholangitis.
- The patient was successfully treated for sepsis but died due to metastatic pancreatic cancer.
- Biliary fluid also contained lactobacilli and saccharomyces in addition to S. pyogenes.

## Abstract

Streptococcus pyogenes (S. pyogenes) is a gram-positive, facultative anaerobic bacterium that appears as cocci in chains and commonly causes skin infections and pharyngitis. Here, we present a very uncommon case of cholangitis associated with invasive S. pyogenes infection in a 34-year-old man with metastatic pancreatic adenocarcinoma who presented with fever, right upper quadrant pain, jaundice, altered mental status, and hypotension. The patient underwent a percutaneous transhepatic cholangiogram, showing moderate dilatation of intrahepatic biliary ducts with obstruction of the proximal common bile duct, and an internal/external biliary drain was placed to allow for the flow of bile. Blood cultures grew S. pyogenes. Biliary fluid culture obtained at the time of drain placement grew S. pyogenes, lactobacilli, and saccharomyces. The patient was treated with ampicillin-sulbactam and fluconazole. While the patient recovered from his sepsis, he died within weeks of diagnosis due to complications of metastatic disease.