CHRONIC COUGH AS THE ONLY PRESENTATION OF PYOGENIC LIVER ABSCESS

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: The most common type of visceral abscesses is liver abscesses, which mostly present with constitutional and/or gastrointestinal symptoms and can rarely have pleuropulmonary manifestation. In contrast to the majority of liver abscesses reported with pleuropulmonary presentation in literature of last few years, which have been mostly in the setting of multiorgan involvement in amoebiasis and hydatid disease or in the setting of rare complications like bronchobiliary fistula formation or pulmonary embolism, herein we report a case of Escherichia coli (Ecoli) pyogenic liver abscess which presented as chronic cough in the setting of pleural reaction without any complications or known underlying contributing risk factors; the cough was completely resolved after drainage of the hepatic abscess and appropriate antibiotic treatment. CASE PRESENTATION: A 72-year old Caucasian male resident of the United States, retired teacher and former cigarette smoker without recent travels, with a past medical history of hypertension, cardiac arrhythmia, and cholecystectomy 5 years ago presented to the pulmonary clinic with chronic productive cough of clear phlegm for 4 months. Outpatient treatment measures had failed and the patient had experienced unintentional weight loss of 7 lb over past 3 months. On the presentation in a pulmonary outpatient clinic, the patient was afebrile with an unremarkable physical examination. CXR reported moderate right hemidiaphragm elevation and right lower lobe atelectasis versus pulmonary opacification. Subsequently, CT of the chest, with and without contrast, was ordered which was suggestive of mild ill-defined reticulonodular groundglass opacities in the right lower lobe indicative of inflammatory change, and a fluid collection was noticed on the posterior liver margin. Hence, the patient was sent to the hospital and a CT of abdomen and pelvis with and without contrast was obtained which confirmed the same pulmonary findings along with large rim-enhancing, 12cm x6cm x11cm, pericapsular fluid collection along posterior liver margin. Labratory workup showed leukocytosis with WBC 13.5K and blood culture and sputum culture results were negative. Empiric treatment with Piperacillin-tazobactam was initiated. CT fluoroscopy-guided percutaneous drainage catheter was placed and the drained fluid was sent for cytology and culture analysis, which was negative for malignancy and positive for E coli. Meanwhile, the patient reported that his cough was completely resolved and the patient was discharged with Ceftriaxone and Metronidazole. After 10 days treatment upon follow up, and negative anaerobic cultures and amebic PCR results, metronidazole was discontinued. The patient was symptom-free after a total of four weeks of treatment with ceftriaxone. A repeated CT of abdomen and pelvis, with and without contrast, was suggestive of resolution of liver abscess and interval decrease in subsegmental atelectasis in the right lower lobe. Hence, the percutaneous drainage catheter was removed. DISCUSSION: Pyogenic liver abscesses constitute almost half of the visceral abscesses and overall 13% of intra-abdominal abscesses. Geographic and host-related factors contribute to pyogenic liver abscess formation. Moreover, diabetes mellitus, regular use of proton pump inhibitors, underlying immunosuppression, diverticular, pancreatic and hepatobiliary diseases and recent laparoscopic procedures or perforated viscus followed by spilled fecalith or gallstones have been listed as the risk factors for the development of pyogenic liver abscesses in the literature. The typical clinical manifestation of pyogenic liver abscesses is fever, abdominal pain, nausea, vomiting, anorexia, weight loss and in rare cases liver abscesses can present as chronic cough like in amoebiasis and hydatid disease in endemic areas, bilioptysis, chest pain and syncope in the setting of seldom complications such as bronchobiliary fistula, pulmonary embolism (PE) including septic PE, pyogenic pericarditis and cardiac tamponade respectively. Unlike the reported liver abscess cases in the literature over the past few years to the best of our review, our case is unique in the setting of no known attributable geographic and host-related risk factors were found in this pyogenic liver abscess case and also in presentation as chronic non-resolving cough without a major pulmonary findings or complications reported in the literature. CONCLUSIONS: In the evaluation of the patient with chronic cough -or other respiratory symptoms- physicians should always pay attention to clinical examinations as well as radiological findings to exclude any extra-thoracic especially sub-diaphragmatic abnormalities as the underlying etiologies of pleuropulmonary clinical manifestation. Reference #1: Ala A, Safar-Aly H, Millar A. Metalic cough and pyogenic liver abscess. Eur J Gastroenterol Hepatol. 2001 Aug;13(8):967-9 Reference #2: Chan KS, Chen CM, Cheng KC, et al. Pyogenic liver abscess: a retrospective analysis of 107 patients during a 3-year period. Jpn J Infect Dis 2005; 58:366. Reference #3: Toukan Y1,2, Gur M1, Nir V1, Bentur L Medical mishap as a cause of non-resolving pneumonia Pediatr Pulmonol. 2017 Oct;52(10):E67-E69. https://doi.org/10.1002/ppul.23737. Epub 2017 May 30 DISCLOSURES: No relevant relationships by Mohammed Al Janabi, source=Web Response No relevant relationships by Pauline Haroutunian, source=Web Response