International Journal of Case Reports and Images - IJCRI - Case Reports, Case Series, Case in Images, Clinical Images

     
Case Report
 
Multidrug resistant pyogenic liver abscesses: A rare but fatal complication of a life-saving procedure
Waqas Jehangir1, Shilpi Singh1, Andrea A Lewis2, Shuvendu Sen3
1MD, Resident, Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, NJ, USA.
2BS, Physician Assistant Student, Rutgers-School of Health Related Professions, Piscataway, NJ, USA.
3MD, Associate Program Director Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, NJ, USA.

doi:10.5348/ijcri-201462-CL-10050

Address correspondence to:
Waqas Jehangir
530 New Brunswick Ave
Perth Amboy, NJ
USA 08861
Phone: +1 267-844-7119
Email: wjehangir@hotmail.com

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How to cite this article
Jehangir W, Singh S, Lewis AA, Sen S. Multidrug resistant pyogenic liver abscesses: A rare but fatal complication of a life-saving procedure. Int J Case Rep Images 2014;5(9):665–667.


Case Report

An 84-year-old Korean female, nursing home resident, was sent to the emergency department after she was discovered to have an altered mental state, lethargy, and low-grade fever. This patient recently underwent a biliary stent placement secondary to ascending cholangitis. Since then, the patient had multiple uncomplicated recurrent infections. Patient had a past medical history significant for hypertension, dementia, dysphagia, deep vein thrombosis (DVT), and cerebral vascular accident (CVA) with right paresis. Her past surgical history included a G-tube placement, inferior vena cava (IVC) filter placement, right ureteral stent placement, craniotomy, cholecystectomy, ventriculoperitoneal shunt, and left cataract extraction. Patient's vital signs included tachycardia, tachypnea, with a blood pressure of 134/71 mmHg. Patient was slightly febrile, and with a saturation of 95% on room air. On physical examination, patient was toxic appearing, awake, yet drowsy and confused. Additionally, patient grimaced to tenderness over the right upper quadrant and had generalized weakness in all extremities, more pronounced on right side. Furthermore, patient was found to have bilateral harsh breath sounds, basilar crackles, and decrease breath sounds. Her extremities showed trace edema. Laboratory tests revealed hemoglobin 12.4 g/dL, white blood cell count of 35.7x103/mm3, platelets 3.27x105/mm3, lactic acidosis, elevated AST, ALT, alkaline phosphatase, and total bilirubin. Additionally, a chest X-ray showed bilateral basilar pneumonia and a small pleural effusion. Based on the laboratory and radiographic findings, patient was admitted to ICU with an assessment of sepsis secondary to pneumonia and to rule out intra-abdominal infection and biliary tract infection. Additionally, patient was started on linezolid and primaxin and a full septic workup was initiated. Computed tomography scan of the abdomen revealed multiple hypodense lesions along the dome/right hepatic lobe with the largest appearing to be multiloculated measuring 6.8x6 cm in the greatest dimension (Figure 1). Hepatic abscesses versus metastatic disease was in consideration. A possible removal of the biliary stents appeared to be technically not feasible because of the patient's hemodynamic instability. A computed tomography scan-guided drainage of large abscesses was then scheduled. Cultures of the abscess drainage showed Enterococcus faecium-Group D, Vancomycin-Resistant (VRE), Morganella morganii, and Pseudomonas aeruginosa. Patient was then started on tigecycliine, amikacin, and linezolid based on sensitivity. However, the patient did not survive and died of septic shock secondary to multidrug resistant pyogenic liver abscess, a complication of biliary stent placement.


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Figure 1: Computed tomography scan of the abdomen without contrast showing multiple hypodense lesions along the dome/right hepatic lobe with the largest appearing to be multi-loculated measuring 6.8x6 cm in the greatest dimension.



Discussion

Pyogenic liver abscesses (PLA) are rare but can be a potentially life-threatening condition [1]. The most common cause in recent data of PLA is biliary disease, which is more prevalent in women. Additional underlying or concomitant causes include but are not limited to: hypertension, intra-abdominal infection, diabetes, malignancy, cardiovascular disease, alcohol abuse and cirrhosis, diverticulitis, and inflammatory disease [2].

Patients with PLA often present to the emergency department with a fever of unknown origin and after a thorough assessment, radiographic studies may be initiated to aid in finding the origin of the fever [3]. Once a PLA is diagnosed, treatment via percutaneous drainage is indicated. Surgery can be an alternative choice. Isolated pathogens of PLA are typically gram-negative bacteria in which Escherichia coli was thought to be the most common usually culprit of pyogenic liver abscesses detected by computed tomography, but new data suggest Klebsiella pneumonia has become the principal etiology of PLA [2] .


Conclusion

In our case, the patient developed a multidrug resistant pyogenic liver abscess, which eventually proved to be fatal.


References
  1. Gungor G, Biyik M, Polat H, Ciray H, Ozbek O, Demir A. Liver abscess after implantation of dental prosthesis. World J Hepatol 2012;4(11):319–21.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: Recent trends in etiology and mortality. Clin Infect Dis 2004;39(11):1654–9.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Golia P, Sadler M. Pyogenic liver abscess: Klebsiella as an emerging pathogen. Emerg Radiol 2006;13(2):87–8.   [CrossRef]   [Pubmed]    Back to citation no. 3
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Author Contributions
Waqas Jehangir – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Shilpi Singh – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Andrea A Lewis – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Shuvendu Sen – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2014 Waqas Jehangir et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



About The Authors

Waqas Jehangir is Internal Medicine Resident at Raritan Bay Medical Center, Perth Amboy, NJ. He earned the Medical degree MBBS from Nishtar Medical College/University of Health Sciences, Lahore, Pakistan. He has published 10 research papers in national and international academic journals. His research interests include hematology and oncology. He intends to pursue fellowship in hematology/oncology.



Shilpi Singh is Internal Medicine Resident and Chief Resident at Raritan Bay Medical Center, Perth Amboy, New Jersey, USA. She earned the undergraduate degree MBBS from Himalayan Institute of Medical Sciences, Dehradun, India. She also has Masters in Public Health from University of New England Maine. She has published multiple research papers in national and international academic journals. Her research interest includes, endocrinology, pulmonary, cardiology and hematology, and oncology. She Intends to pursue fellowship in pulmonary/critical care.



Andrea Lewis is enrolled in the dual master degree program of Physician Assistant/Public Health and Rutgers University in Piscataway, New Jersey. She earned her BS in Microbiology from the University of Louisiana at Lafayette. Her area of interest includes weight loss and nutrition. Her masters project studied weight loss advertisements in women's health and fitness magazines. After graduation, she plans on working in primary care and being over a community outreach program.



Shuvendu Sen is MD, Associate Program Director Department of Internal Medicine, Raritan Bay Medical Center, Perth Amboy, NJ, USA.




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