S2896 Encysted Empyema: An Uncommon Complication of Pyogenic Liver Abscess

Abstract

Introduction: Pyogenic liver abscess (PLA) is uncommon in the U.S. with an estimated incidence of 8-15 cases per 100,000 persons and has a mortality rate between 15% and 20%. Despite being a rare complication, PLA has been found to increase 18 times the risk of pleural empyema. Case Description/Methods: A 36-year-old woman with presented to the emergency department with intractable right hypochondrial and shoulder pain. HPI: 2 weeks before the presentation the patient developed right hypochondrium and epigastric pain, radiating to the right shoulder, dull aching, gradually worsening, associated with nausea, vomiting. PMH: Hypertension, Asthma, and Lactose intolerance. Physical Exam : The patient was found to be afebrile, Elevated blood pressure, mildly distressed due to severe abdominal pain. Abdomen: Normoactive bowel sounds. soft, non distended, tender to palpation in RUQ, No rebound tenderness, No gardening. Clinical Course: • CT of the abdomen demonstrated right hepatic lobe abscess. • The patient was started on empiric antibiotic coverage with cefepime and metronidazole. • CT-guided liver abscess drainage and pig tail catheter placement resulted in drainage of 200 cc of foul-smelling, thick, maroon-brown fluid. • Fluid culture was positive for K. pneumoniae sensitive to ceftriaxone. • Despite drainage of the abscess and appropriate antibiotic coverage the patient’s condition deteriorated as she developed signs of sepsis with worsening right sided chest pain and leukocytosis. • Repeat CT of the chest showed a newly formed right-sided large multiloculated pleural effusion concerning for empyema. • Patient underwent video-assisted thoracoscopic surgery decortication and laparoscopic liver abscess drainage and marsupialization. • The patient improved after these interventions and was discharged one week after the procedure with a plan to continue oral ciprofloxacin for 10 days. Discussion: PLA of the right hepatic lobe with exophytic extension to the posterior thoracic wall is a risk factor for the development of an encysted pleural effusion complicated by empyema. Image guided percutaneous drainage is the most reliable method for both diagnosis and treatment of a single, unilocular liver abscess. However, this procedure may increase the risk of developing a pleural effusion and subsequent empyema suggesting that these cases may benefit from early surgical intervention rather than image guided drainage.Figure 1.: Triphasic CT abdomen and pelvis; Liver: There is a 7.0 x 6.8 x 8.0 cm peripherally enhancing lesion in the posterior RIGHT hepatic lobe., with exophytic extension to involve the posterior wall of the lower thorax and adjacent retroperitoneum.