bloodstream recurrent infections have been reported for a great variety of opportunistic bacteria , with coagulase - negative staphylococci being the most common .
the majority of the relapsing sepsis infections are either catheter related or are caused by indwelling devices that serve as an excellent solid phase for sticky biofilms , the source for transient bacterial translocation into the vessel lumen .
molecular fingerprinting ,   as well as biochemical analysis and serotyping   have shown that the majority of the sepsis episodes might be caused by the same strain even when adequate antimicrobial therapy is provided .
taking into account the multistrain and multispecies complexity of biofilm , it remains unclear why sepsis episodes are often caused by exactly the same strain and what kind of  leads  this strain may have compared to other 
altogether , the patient experienced seven episodes of e.  coli bacteraemia in just over a year .
all the episodes can be considered as relapses caused by the extended - spectrum -lactamase ( esbl ) strain or by the ampc hyperproducer . finally , the focus of these bloodborne infections was found in his spleen and pancreas cauda , which was resected . of interest ,
the underlying disease , autoimmune pancreatitis of type 1 with igg4 hyperglobulinaemia , had probably contributed to the formation of the cyst that harboured infection .
a 47-year - old man came to finland as a refugee from southeast asia . in the immigration health inspection , he was diagnosed with a toxocara canis infection and treated with mebendazole .
soon after arrival , he complained of epigastric pain and fever ; he was diagnosed with acute pancreatitis , which was treated conservatively .
pancreatitis episodes , often complicated with septicaemias , recurred several times during the following years .
three years after the first pancreatic episode , the patient was hospitalized again for fever and multiple liver abscesses .
drainage of abscesses was not feasible because of the small size of the multiple abscesses and the challenging anatomic site .
an infection of the pancreatic duct stent was suspected , and the stent was removed .
instead , toxocara canis serology remained positive , compatible with his early infection . during the following months , the patient was hospitalized several times for recurrent pancreatitis and relapsing episodes of sepsis .
abscess formation continued even though the patient received various antimicrobials ( table  2 , table  3 ) .
in addition to resection of the pancreatic cauda , the enlarged spleen was removed , and cholecystectomy was performed .
histopathologic examination of the pancreas revealed extensive fibrosis , multiple cysts ( 12  cm in diameter ) and inflammatory cells such as neutrophils , macrophages , lymphocytes and plasma cells that were partly immunopositive for igg4 .
the hilum of the spleen revealed purulent inflammation , but the splenic parenchyma and gallbladder were structurally normal .
computed tomographic scan revealed numerous degenerative cystic lesions in the spleen that most probably had formed as a result of prolonged bacterial infection ( fig .  1 ) .
a pseudocyst filled with a grey fluid was found between the pancreatic cauda and the spleen .
all other tissue cultures were negative in bacteriologic , mycobacteriologic , virologic and parasitologic examinations .
these findings finally confirmed suspected end - stage chronic autoimmune pancreatitis associated with the igg4 syndrome . during convalescence
, the patient had a relapse of esbl e.  coli sepsis but recovered completely .
three other e.  coli isolates ( table  1 ) had an ampc phenotype and were negative for ampc genes ( cit , dha , mox , fox , ebc , acc ) , thus apparently overproducing the chromosomal ampc . in order to investigate the clonality of the strains
the culture isolates were analysed with pulsed - field gel electrophoresis using a protocol based on pulsenet for e.  coli ( http://www.cdc.gov/pulsenet/pathogens/ecoli.html ) .
briefly , genomic dna was digested with xbai ( new england biolabs ) , and separated in a chef dr iii ( bio - rad ) .
the esbl isolates were found to be the same strain ( one- to two - band differences in the banding patterns ) .
the ampc overproducers were also similar ( a one - band difference in one isolate ) ; however , they were different from the esbl clone ( fig .  2 ) . soon after the surgical intervention , our patient experienced a new episode of esbl sepsis  a complication that might have been avoided if previous bacteriologic data had been taken into account so perioperative carbapenem prophylaxis could have been implemented .
the reported case emphasizes that the primary prevention of bloodstream relapses caused by gram - negative bacteria is the surgical elimination of the focus of infection . being encapsulated in a cyst , the bacteria are well protected against the bactericidal action of antimicrobials even in organs with good vascularization such as the pancreas .
relapses of bacteraemia with enterobacteria can occur in patients with underlying gastrointestinal or autoimmune disorders , as in our case .
these episodes can be caused by resistant bacteria , which should be considered during perioperative protection after the first sepsis episode .
 bloodstream recurrent infections have been reported for a variety of opportunistic bacteria . 
 these are often either catheter related or are caused by indwelling devices . a case of relapsing sepsis with two escherichia coli strains carrying extended - spectrum -lactamase and derepressed ampc genes 
 is reported . 
 the patient had seven episodes of bloodstream infections within 1 year and was diagnosed with chronic autoimmune pancreatitis and igg4 hypergammaglobulinaemia . 
 abscesses were found in his spleen and pancreas cauda , which was finally resected . 
 relapses of bacteraemia with resistant enterobacteria should be considered during perioperative protection . 
 surgical removal of the infective focus could be curative . 
Introduction
Case Report
Discussion
Conflict of Interest