Intrauterine Device Related Hepatic Abscess

Abstract

Hepatic Actinomycosis is a rare, but well documented cause of liver abscess. Recent literature has demonstrated the relationship of intrauterine devices (IUD) and infection with Actinomycoses. Infections caused by Capnocytophaga species occur infrequently but usually present in patients that are immunocompromised. A 42 year old Polish female with no significant past medical history, presented with a month of upper abdominal fullness, loss of appetite, nausea, and weight loss of 30 lbs. On exam she was cachectic with right upper quadrant tenderness and hepatomegaly. Lab values were notable for WBC's of 12.1 with 27% bands, an alkaline phosphatase of 493 U/L, AST of 48 U/L, ALT of 45 U/L and albumin of 2.5 g/dL. A CT of the abdomen showed dilatation of the intrahepatic ducts, 2 large subcapsular fluid collections in the right lobe of the liver, a large fluid collection in the pelvis and the presence of an IUD. An ERCP demonstrated multiple saccular dilatations of the intrahepatic ducts and two cystic areas in the liver communicating with the biliary tree. Papillotomy was performed with drainage of purulent fluid. The patient underwent CT-guided drainage of the fluid collections in the right lobe of the liver and the pelvis, with removal of 700 ml of pus. The patient was started on piperacillin/tazobactam and the IUD was removed. The patient improved and cultures of the hepatic abscess eventually grew A. israelii and C. ochracea and the pelvic abscess grew A. israelii also. However the patient had a seizure 7 days into antibiotic therapy and CT of the head revealed 3 ring-enhancing lesions, consistent with metastatic abscesses. The patient was started on phenytoin and the antibiotics changed to ceftriaxone and metronidazole. Repeat CT of the abdomen showed resolution of the abscesses. The patient subsequently did well and eventually went home on long-term antibiotic therapy. Actinomyces and Capnocytophaga species are both endogenous to the oral flora and occasionally can be found in the gastrointestinal and vaginal tracts. Hepatic Actinomycosis accounts for 5% of all infections with Actinomyces species. Risk factors include poor dentition, appendicitis, prior abdominal surgery, immunosuppression and IUD use. Most infections with Capnocytophaga occur in immunocompromised patients with poor dentition and clinically manifest as bacteremia, endocarditis, osteomyelitis or empyema. An extensive literature review revealed only one case report of liver abscess due to Capnocytophaga.