🫀 Enterococcal Endocarditis? Don’t Forget to Ask About Bowel Cancer

Published on: July 26, 2025

Author: Team FRCPathPrep

Category: Infective Endocarditis, Enterococci, Clinical Pearls

🧬 A Case of Endocarditis… and a Hidden Cancer?

You’ve just diagnosed a patient with enterococcal endocarditis, confirmed on blood cultures and echocardiography. But there's a vital next question that might not appear in your guidelines —

Have you investigated for bowel malignancy?

🧫 The Link Between Enterococci and Colorectal Cancer

While Streptococcus gallolyticus (formerly S. bovis) is the classic organism associated with colonic neoplasia, increasing evidence points toward a similar concern with enterococci — especially Enterococcus faecalis.

Why?

• Enterococci, particularly E. faecalis, are part of the normal gut flora.

• Mucosal breach in colorectal cancer can allow translocation of these organisms into the bloodstream.

• Repeated low-level translocation may lead to subacute or chronic infective endocarditis.

🔬 Mechanism: Gut Barrier Breakdown ➝ Bacteraemia ➝ Endocarditis

Colorectal tumors (especially right-sided or advanced adenomas):

• Disrupt the epithelial barrier

• Create a pro-inflammatory microenvironment

• Allow microorganisms like enterococci to access the bloodstream

🧠 In these patients, enterococcal bacteraemia or endocarditis is often a sentinel event.

🏥 Clinical Scenario (FRCPath Part 2 OSPE-Style)

A 68-year-old man presents with fever and weight loss.Two sets of blood cultures grow E. faecalis at 18 hours. TTE shows a mitral valve vegetation.

❓ What further history or investigations should you pursue?

✅ GI symptom review✅ FOBT / FIT✅ Colonoscopy referral

📝 FRCPath Exam Tip

• 📌 If enterococcal endocarditis is present, and there is no clear urinary, biliary, or procedural source, always mention evaluation for occult GI pathology.

• Especially for E. faecalis and in older male patients.

📚 Supporting Evidence

• E. faecalis produces extracellular superoxide, linked with DNA damage and colon tumorigenesis (Huycke et al., 2002)

• Retrospective studies have found higher prevalence of colorectal neoplasia in patients with enterococcal bacteraemia/endocarditis.

🔎 Summary Table

Feature	S. gallolyticus	E. faecalis
Colon cancer link	Strong, well-established	Emerging, under-recognized
Endocarditis presentation	Subacute, culture-positive	Similar pattern
Site of origin	Colon mucosa	GI tract (esp. malignancy-associated)
Recommended action	Mandatory colonoscopy	Strongly consider colonoscopy

💡 Key Takeaway:

If you find enterococcal endocarditis — especially without a clear source — always think beyond the heart.Ask about bowel symptoms.Consider occult malignancy.A colonoscopy may save a life.

📘 Learn More with FRCPathPrep

🩺 OSPE cases on endocarditis with systemic clues🧪 Blood culture interpretation and infection source mapping📊 SAQs covering GI associations of bloodstream infections

👉 Available now at www.FRCPathPrep.com