S3519 Septic Pulmonary Emboli From Pyogenic Liver Abscess After Cholecystectomy

Abstract

INTRODUCTION: Pyogenic liver abscess(PLA) is potentially fatal with an incidence of about 1 in 45 to 100,000, with significant mortality rate of 6% to 19.6%. Most frequent isolated microorganisms are Escherichia(E) Coli and streptococcus millery group. In the past 2 decades, Klebsiella pneumonia has been reported to be the most common pathogen causing PLA, especially in Asia and the US with higher probability of hematogenous spread and metastatic infection. CASE DESCRIPTION/METHODS: 38 year old female with a history of cholesystectomy, complicated by biliary leak and stenosis in common hepatic duct s/p ERCP with stent placement. Few weeks later, patient developed pyogenic liver abscess growing Klebsiella pneumonia, confirmed by CTAP(CT of abdomen and pelvis) and blood culture. Patient was placed on 1 week course of antibiotics after CT guided aspiration and got discharged. 3 months later, patient presented with flank pain. Ultrasound of the abdomen did not show any signs of abscess. However, blood culture grew K. pneumonia for which patient was given another 1 week course of antibiotics. 1 week later, patient comes back again with chief complaint of abdominal pain, pleuritic chest pain with fever and chills. Repeat CT scan showed hypodensity in the lateral mid right hepatic lobe, suggestive of abscess. CTPA showed peripheral fill defect and nodular changes in right lower lobe in which septic emboli is highly likely. DISCUSSION: As complications of liver abscesses due to high rates of bacteremia, patients can sometimes develop pulmonary septic embolism, caused by clot, fibrin matrix and micro-organisms. Other complications include right sided endocarditis, pelvis thrombophlebitis. The main features on CT scan on septic pulmary emboli is feeding vessel sign(79%), nodules with or without cavitations (79%) and subpleural wedge shaped subpleural opacities (64%). Abdominal imaging raises high suspicion of this condition. CT is more sensitive than ultrasound for liver abscesses (approximately 95 versus 85 percent). Key component of the management is drainage of abscess guided by either CT or ultrasound, ERCP, followed by appropriate duration of the antibiotics. If the location is difficult to be accessed, open surgical drainage, laparoscopic drainage should be indicated. Antibiotics therapy should be continued for two to 4 weeks for complete drainage and 4 to 6 weeks for the incomplete drainage.Figure 1.: Gas forming sub capsular fluid collection in the the right lobe of the liver, suggestive of pyogenic liver abscess.Figure 2.: Abnormal hypo density lateral mid right hepatic lobe, consistent with persistent pyogenic liver abscess.Figure 3.: Feeding vessel sign, distinct branch of pulmonary artery directly leading to a nodule. This is one of the specific findings of septic pulmonary emboli.