DOI: 10.1097/01.ccm.0000475081.70059.96
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Issn Print: 0090-3493
Publication Date: 2015/12/01
Justin Tsai; Ihsan Asbahi; Jinesh Lachmansingh; Robert Johnston
Excerpt
Case Report: Pyogenic liver abscess is a rare condition with a high mortality rate; it infrequently presents as a gas forming variant. The majority of gas forming pyogenic liver abscesses are caused by Klebsiella pneumoniae, but occasionally by Clostridium, Bacteroides, and anaerobic streptococci as well. Frequent co-morbidities are poorly controlled diabetes, immunosuppression, and gastrointestinal malignancy. We present a case of massive gas-forming multi-Clostridium species liver abscess with accompanying sepsis, initially misdiagnosed as bowel perforation. A 54-year-old male with a history of unexplained anemia, asthma, hypertension, and gout presented with nausea and emesis for 1 day, with a blood pressure of 92/67, a heart rate of 89, and a white blood cell count of 7.4. CT revealed a massive 20 x 17 x 16.5 cm gas filled structure in the epigastrium, portal venous air, and free air in the abdomen. The patient was taken emergently to the operating room with presumptive bowel perforation. Surgical exploration revealed massive amounts of hepatic air actively bubbling from Glisson’s capsule and a mid-jejunal mass, which was resected. The patient was admitted to the SICU where fluid resuscitation and vasopressor support continued, and was empirically treated with ertapenem, metronidazole, and micafungin. On hospital day 3, admission blood cultures grew Clostridium perfringens, and clindamycin was added. The patient was weaned off of pressors and extubated; however, imaging revealed minimal improvement and the emergence of additional gas filled abscesses. Interventional radiology was consulted and 4 hepatic drains were placed; drain samples grew Clostridium septicum. Pathology results from the resected mass and abdominal lymph nodes revealed metastatic melanoma, and a primary lesion was found on the patient’s back. This small bowel lesion likely seeded enteric Clostridium into the portal venous system. The patient was placed on a 6 week course of clindamycin and ertapenem, and discharged on hospital day 15, with plans to undergo FOLFOX chemotherapy when recover.
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