MOFFITT AM REPORT PEARLS 9/6/16: Enterococcal Infections and IgG4-Related Disease!

Thanks to Hana for presenting a crazy case of hepatobiliary enterococcal infection on a background of IgG4 disease! Wow!


Top 2 pearls from today:

*Don’t forget about enterococcus as a possibility when cultures are “likely strep”!

*Your go-to antibiotic for enterococcal infection is usually vancomycin.



Gram positive cocci formerly known as “group D strep” (no longer considered streptococcus genus)

Manifestations: UTI, bacteremia, endocarditis, meningitis.

2 major species: E. faecalis and E. faecium

There are also non-faecalis, non-faecium species as we heard in report!

E. faecalis: more virulent but generally ampicillin and vancomycin susceptible.

E. faecium: less virulent but generally ampicillin and vancomycin resistant.

Empiric tx: Most popular choice is vancomycin monotherapy since ampicillin resistance is common or daptomycin if high prevalence of VRE (e.g. nosocomial infection). In critical illness, endocarditis, or meningitis, consider synergistic therapy (various combinations of vanc, gentamicin, ampicillin, ceftriaxone), but Harry says the cell wall agent (vanc/amp/dapto) is still the most important to get on board for sick patients with enterococcal infections.


IgG4-related disease:

Idiopathic, most common in middle-aged/older men

Can manifest in almost any organ (as a subacute mass or diffuse organ enlargement)!

  • Autoimmune pancreatitis
  • Sclerosing cholangitis
  • Salivary/lacrimal gland and orbital involvement
  • Retroperitoneal fibrosis
  • Chronic sclerosing aortitis and periaortitis
  • Thyroiditis
  • Interstitial pneumonitis
  • Renal disease (interstitial nephritis)
  • Lymphadenopathy


Need tissue for dx: infiltration with IgG4 positive plasma cells and lymphocytes

Most patients have elevated serum IgG4 levels (suggestive but not diagnostic)

Good response to glucocorticoids is characteristic



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