S2653 Candida Liver Abscesses Due to a Penetrating Duodenal Ulcer

Abstract

Introduction: Fungal infections of the liver commonly occur in patients with neutropenia, hematologic malignancies, and chemotherapy. The most common isolated agents are species of the Candida family, originating from the translocation of the gastrointestinal tract to the liver. Here, we present a rare case of multiple fungal abscesses in an immunocompetent host due to a perforating duodenal ulcer. Case Description/Methods: A 59-year-old man with COPD, hypertension, peptic ulcer disease, and obesity presented for altered mental status and fever. He was found to have right lower lobe pneumonia and complete heart block treated with antibiotics, temporary transvenous pacing then leadless permanent pacemaker. During his stay, he presented with melena. He underwent an upper endoscopy that showed a large 40 mm nonbleeding cratered duodenal ulcer with possible perforation and a superficial gastric ulcer with a flat pigmented spot. A CT scan of the abdomen and pelvis showed 3 perihepatic fluid collections along the left lobe, right lobe, and gallbladder fossa with the largest measuring 9cmx1.5cmx9cm and associated pneumobilia. There was no intra-abdominal free air. The patient was clinically stable, afebrile, and denied significant abdominal pain. There were no signs of peritoneal irritation on the physical exam. He did have a persistent neutrophilic leukocytosis with a white cell count of 18,400/ml, Hemoglobin 9g/dl, total bilirubin 0.6 mg/dl, AST 29 IU/l, ALT 38 IU/l, Alkaline phosphatase 53IU/L. The patient was managed conservatively with broad-spectrum antibiotics and proton pump inhibitors. He underwent urgent percutaneous drainage of the 2 largest abscesses. Cultures from the collections grew Candida albicans only. Blood cultures were negative. Thus, the patient was treated with micafungin then transitioned to fluconazole for a 6-week course of therapy. Amoebic and Echinococcus antibodies, and HIV tests were negative. A follow-up CT showed resolution of the liver collections. Discussion: This is a rare case of candida liver abscesses as a complication of a penetrating large duodenal ulcer successfully treated with conservative management. Pyogenic liver abscesses are unusual presentations of perforated gastroduodenal ulcers. In addition to the drainage of the collections, antifungal agents should be considered in the initial antimicrobial regimen choice even in immunocompetent hosts.Figure 1.: From A to C: CT demonstrated liver abscesses (frontal and axial views); D: Upper endoscopy showing a cratered duodenal ulcer.