Intra-abdominal Actinomycosis 11 Years After Spilled Gallstones at the Time of Laparoscopic Cholecystectomy

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A 72-year-old woman with a remote surgical history of a laparoscopic cholecystectomy (LC) complicated by gallstone spillage presented with fever, 3 weeks of nausea and anorexia, and increasing right upper quadrant abdominal pain. After the LC performed 11 years before symptom presentation, the patient was found to have a fluid collection in the right upper quadrant. The patient was asymptomatic at the time, and had no symptoms while being monitored with sequential scans over the next 5 years. At presentation, computed tomography scans revealed a subhepatic, lobulated fluid collection and a radioopacity, consistent with a gallstone, at the inferior aspect of the fluid collection. Subsequent percutaneous drainage of the fluid collection yielded pus that eventually grew Actinomyces israelii. Intravenous clindamycin therapy was initiated, and with further drainage, the abscess resolved. Intra-abdominal abscess formation can present as a delayed complication dropped stones during LC, but these cases usually present within a few years of the procedure. In this case, however, an intra-abdominal abscess formed 11 years after the LC. This extended duration from surgical manipulation to symptom onset is likely secondary to the indolent nature of the infecting organism, A. israelii.

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