A Case of Liver Abscess Presenting as Acute Hemoglobin Drop in a Patient With History of Gastrointestinal Bleeding (GIB)

Abstract

Objective: A liver abscess can be caused by multiple organisms including c. perfringens. It is also known to cause a variety of other clinical manifestations, including gas gangrene, cellulitis, fasciitis, and gastroenteritis. Additionally, c. perfringens is a rare but well-documented cause of intravascular hemolysis. This acute drop in hemoglobin can mimic GIB in pt with h/o bleed and can lead to extensive and invasive workup. It should be suspected especially in a patient who initially presented with gastrointestinal manifestations or liver abscess. Methods: Our patient was a 90-year-old male with a recent history of upper GIB who was presented with right upper quadrant pain, fever, and jaundice for 5 days. Laboratory data showed a hemoglobin of 9.9 g/dl, platelet count of 304,000 /mm3, total bilirubin of 8.4 mg/dl, and direct bilirubin of 3.4 mg/dl. On computed tomography (CT) scan of the abdomen, there was a collection of an abscess within the right lobe of the liver which was emergently drained by interventional radiology and 15 ml of purulent fluid drained and sent for culture. Follow-up laboratory results after drainage revealed a hemoglobin of 6.1 g/dl. With concern for post-procedure perihepatic hematoma, a stat CT scan was done. This showed only regression of abscess with no hematoma. An urgent upper GI endoscopy(ss pt had h/o recent GIB) was also negative for any acute bleed. It was found that pt had hemolytic anemia with negative coomb's test. Later pt's blood culture grew c. perfringens and it was thought to be the culprit of acute Hb drop. He was transfused once and was continued on appropriate antibiotics. His Hb stayed stable after antibiotics treatment.Figure: Initial CT Abd/pelvis: There was a gas containing structure with debris present within the right lobe of liver suspicious for an abscess. A necrotic mass (such as a hepatic metastasis) was an additional possibility.Figure: Stat CT Abd/pelvis s/p IR Drainage of Abscess: Indication: Acute Hb Drop There was Small amount of free air and free fluid around the liver which was related to the recent liver abscess drainage. No retroperitoneal or intraperitoneal hematoma was noted.Figure: Initial USG Abd: A Gas containing right lobe of liver lesion with a second fluid containing lesion at the extreme dome of the right lobe of liver suspicious for abscesses.Conclusions: C. perfringens is a normal GI flora which is a rare but well-documented cause of intravascular hemolysis. This acute drop in hemoglobin can mimic GIB especially in a patient with h/o GIB. This case report highlights the importance of early identification of C-perfringens infection which can help us prevent further C-perfringens associated complication and unnecessary workup.