2319 A Case of Cryptogenic Liver Abscess in a Young Uncontrolled Diabetic

Abstract

INTRODUCTION: Pyogenic liver abscess (PLA) is a rare complication of Diabetes Mellitus, usually seen in older adults who have had diabetes for many years. There is little information regarding the effects of glycemic control on the characteristics of PLA in diabetic patients. Actinomycosis is an infrequent invasive bacterial disease with indolent and non-specific presentation, therefore diagnosis is quite difficult to make for clinicians. Here, we report an uncontrolled diabetic patient who developed cryptogenic Actinomyces odontolyticus bacteremia and concurrent polymicrobial liver abscess. CASE DESCRIPTION/METHODS: A 41-year-old male with a history of uncontrolled Diabetes Mellitus Type 2, presented with severe, dull, epigastric pain. He was found to be in septic shock and diabetic ketoacidosis, requiring admission to the medical intensive care unit. Initial laboratory tests showed a white blood cell count of 16,800/mm3 (87% neutrophils), bicarbonate 14mmol/L, AST 147, ALT 126, alkaline phosphatase 193, beta hydroxybutyrate 5.04, and anion gap 17. HIV testing was negative. Hemoglobin A1c was 13%. A computed tomography (CT) image of his abdomen revealed a 7cm gas containing lesion in the left hepatic lobe concerning for hepatic abscess. He was started on empirica vancomycin and piperacillin/tazobactam and subsequently underwent CT-guided pigtail catheter insertion for drainage of the abscess. Microbiological examination of the drainage revealed polymicrobial pus including rare actinomyces. His blood cultures revealed actinomyces odontolyticus. He improved hemodynamically and repeat blood cultures were negative. He was discharged on IV Penicillin G and Metronidazole with duration dependent on resolution of abscess. Once infection is resolved, he will undergo colonoscopy and dental examination to identify possible source for infection. DISCUSSION: The incidence and morbidity of patients with PLA and diabetes has recently increased. Hyperglycemia can promote bacterial growth in tissues, and metabolic disorders impact the gastrointestinal tract. Diabetes can also promote infection through reduced immunity, neutrophil chemotaxis, mononuclear phagocyte activation, and opsonization. Actinomyces Odontolyticus is rare, especially in the absence of other pathology, and many conditions have been described as a possible initiating event including diverticulitis, appendicitis or peptic ulcer disease. A multi-team approach is always recommended when disseminated actinomycotic infection is observed.