S6425 When the Gut Speaks From the Spleen: A Rare Case of Streptococcus gallolyticus Splenic Abscess in a Patient With Polycythemia Vera

Introduction: Streptococcus gallolyticus bacteremia is classically associated with colorectal neoplasia, often leading to early gastroenterology involvement. However, its identification in rare extraintestinal infections, such as splenic abscess, is less recognized. We present a diagnostically challenging case of splenic abscess in a patient with polycythemia vera (PV), highlighting the intersection of hypercoagulability, visceral infarction, and gut-origin bacteremia. Case Description/Methods: A 61-year-old man with polycythemia vera (PV), ischemic cardiomyopathy (EF 50–55%), coronary artery disease post-PCI, recent transcatheter aortic valve replacement (2/2025), and chronic kidney disease stage 3 presented with acute chest pain and profound hypotension. Computed tomography angiography abdomen revealed a suspicious splenic infarct. He was admitted to the ICU, resuscitated with fluids, and started on norepinephrine. Blood cultures grew Streptococcus gallolyticus, prompting a transesophageal echocardiogram, which ruled out endocarditis. Repeat imaging within days showed transformation of the infarct into a splenic abscess. He underwent computed tomography (CT)-guided percutaneous drainage. Fluid cultures yielded S. gallolyticus and Streptococcus alactolyticus. The patient was started on a 6-week course of intravenous ceftriaxone. Interval imaging showed partial resolution of the abscess. Given the microbiologic findings and their association with colonic neoplasia, an outpatient colonoscopy was strongly advised. Hydroxyurea was continued for PV. The patient remained clinically stable and was discharged with close infectious disease and hematology follow-up. Discussion: S. gallolyticus bacteremia—even in the absence of endocarditis—warrants gastrointestinal evaluation due to its well-established association with colorectal malignancy. In this case, a splenic abscess revealed a gut-derived pathogen in a patient with an underlying hypercoagulable state. The presentation underscores the importance of recognizing how gastrointestinal organisms can drive systemic infection and signal the presence of occult malignancy. To our knowledge, this is the first reported case of a splenic abscess in a patient with polycythemia vera, occurring without a clearly defined primary source. This unique presentation expands the clinical spectrum of complications associated with PV and highlights the need for vigilance in evaluating atypical infections in this population.