Streptococcus bovis endocarditis and carcinoma of the colon.

Sir, The association between Streptococcus bovis endocarditis and carcinoma of the colon is well documented.'-5 We report a patient in whom, following treatment of S. bovis endocarditis, a right hemicolectomy was carried out for a caecal lesion which, although biopsies had shown benign disease, the subsequent postoperative histology revealed the presence of an adenocarcinoma. An 83 year old man was admitted and treated for an infective exacerbation of his chronic obstructive airways disease. He had a past medical history of myocardial infarction, congestive cardiac failure, mitral regurgitation and pernicious anaemia. In 1989 a sigmoid colotomy had been performed for a villous adenoma found following investigation of an iron deficiency anaemia. Five days after discharge he was readmitted complaining of malaise, backache and headache. He was pyrexial. Blood culture grew S. bovis and transoesophageal echocardiogram demonstrated vegetations on the mitral valve. Following commencement on intravenous teicoplanin, the patient improved rapidly, with no recrudescence ofhis initial pyrexia. The patient denied any bowel symptoms and faecal occult bloods were negative, but at colonoscopy a large polypoid lesion of malignant appearance was seen just above the ileo-caecal valve. A number of smaller polyps were also seen. Caecal biopsies showed no malignancy. In view of the macroscopic appearance of the caecal lesion, the association of malignancy with S. bovis endocarditis, and the possibility of recurrence of the endocarditis, an elective right hemicolectomy was carried out. At operation three polyps were found in the caecum. Histological examination of the largest polyp revealed a moderately differentiated adenocarcinoma Dukes stage A. The other two polyps were tubulo-villous adenomata and three lymph nodes were free from tumour. This case emphasizes the need for a high index of suspicion of malignancy and thorough gastrointestinal investigation, even in the absence of gastrointestinal symptoms, in cases of Streptococcus bovis endocarditis or bacteraemia. Colonoscopy is the investigation of choice as barium enema failed to detect the presence of carcinoma in some reports.6'7 L.G. Copeland M.G. Malster Department of Geriatric Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool L7 8XP, UK.