An Unusual Case of Hepatic Abscess After Rectal Use of Crystal Methamphetamine

Abstract

Pyogenic Liver abscess occurs most commonly as a complication of biliary tract infection. We describe the first case of hepatic abscess developing in a patient with colitis secondary to rectal methamphetamine use. A 35 year old gentleman presented with RLQ abdominal pain, loose stools with mucus and painful defecation for 4 days. He is a homosexual male with a history of HIV on HAART, recurrent pancreatitis and multiple episodes of infectious colitis. A week before the symptoms, he had receptive sex, and used methamphetamine rectally. On admission, he was afebrile with stable vital signs and RLQ tenderness. Labs revealed mild leukocytosis, and elevated LFTs. CT scan was suggestive of an infectious or inflammatory proctocolitis, and a new 1.9 cm hypodensity in the right hepatic lobe. MRI of the abdomen showed 3.0 cm multi-loculated cystic collection representing intrahepatic abscess, with no significant biliary dilation. Rectal swab was positive for chlamydia, stool was negative for other pathogens including cyclospora and cryptococcus, viral hepatitis panel was negative. He was placed on meropenem for 6 weeks, and the abscess resolved. Pyogenic liver abscesses are the most common kind of visceral abscesses, usually arises in the setting of biliary disease, and less commonly as a consequence of portal vein pyema secondary to diverticulitis, appendicitis, perforated or penetrating peptic ulcer, GI malignancy, IBD, or peritonitis, in many cases it can be cryptogenic. The right lobe of the liver is usually affected, having better blood supply than the left or caudate lobes. We describe a rare case of pyogenic liver abscess in the setting of proctocolitis, in an MSM patient using rectal methamphetamine. There was no recent travel history that would suggest amoebic abscess, and no biliary disease was evident on imaging. There are only a few cases in the literature of transrectal use of methamphetamine, with associated methamphetamine toxicities. However, this is the first case that describes inflammatory colitis associated with methamphetamine use, and the only case to describe liver abscess in this setting. Transrectal methamphetamine abuse and rectal body stuffers are becoming more common, especially in the MSM community, and should be recognized as a possible cause of colitis, and pyogenic liver abscess.Figure 1Figure 2