Development of Hepatic Abscesses Following International Travel

Abstract

A 19 year-old woman presented to the emergency department with a one-week history of progressively worsening right-sided abdominal, shoulder, and rib pain. Her occupational history included service in the navy's culinary department with recent 5-month travel to Oman, Bahrain, Jordan, and Spain. Vital signs were significant for a temperature of 103.1 degrees Fahrenheit and tachycardia to 132. She had exquisite tenderness of the right upper abdominal quadrant with mild guarding. The patient noted recent ingestion of authentic foods from the countries which she visited. She was admitted to the general internal medicine inpatient service. While in the emergency department, right upper quadrant ultrasound was performed. CT of the abdomen and pelvis was later ordered for further characterization of hepatic findings on ultrasound. Empiric therapy with IV metronidazole and ciprofloxacin was initiated. Blood and urine cultures were drawn. Interventional Radiology was consulted for CT-guided aspiration of liver findings on imaging. Initial CBC showed a leukocytosis of 21.5K with 81% neutrophils. Alkaline phosphatase was 146 and INR 1.8. Right upper quadrant imaging demonstrated heterogenous liver parenchyma with multiple cystic lesions in the right hepatic lobe, with the largest measuring 1.3 cm. CT scan of the abdomen confirmed diffusely distributed, peripherallyenhancing cysts in the posterior right hepatic lobe. Extrahepatic biliary ductal prominence was present measuring 4mm in largest diameter. CT-guided aspiration of the largest cystic lesion was performed. Gram stain showed numerous RBCs, few WBCs, and no organisms. Serum serology for Brucella returned positive. Brucellosis is one of the most widespread zoonoses worldwide. Humans may contract the infection through the ingestion of unpasteurized milk, cheese, raw or undercooked meat as well as through the entry of the bacteria through skin lesions, conjunctiva, or by inhalation. The clinical presentation of infection is broad, ranging from asymptomatic to fatal. Gastrointestinal involvement may lead to pancreatitis, cholecystitis, ileitis, colitis, spontaneous peritonitis, splenic or hepatic abscesses, or hepatitis. The take home message for this case demonstrates the importance of recognizing gastrointestinal involvement by Brucella organisms and also acknowledgement of travel history and occupational exposure when presented with new onset abdominal pain.