Salmonella Liver Abscess in a 23-year-old Patient 2 Years after Cholecystectomy

Abstract

Purpose: Pyogenic liver abscess can develop following leakage of intraabdominal bowel contents, through the portal circulation, direct spread from biliary infection or from hematogenous seeding during infection. They are most common in right lobe and commonly caused by enteric gram-negative bacilli (E. coli, Klebsiella), anerobes and also by S. aureus or group A streptococci. Uncommon causative agents include Salmonella, Haemophilus, and Yersinia. A 23-year-old African-American female with past medical history of asthma, cholecystitis with hydropic gallbladder and laparoscopic cholecystectomy 2 years prior presented with epigastric and right upper quadrant pain present intermittently since surgery. Patient denied any fever, chills, nausea, vomiting, jaundice or any weight loss. She had no recent travel or sick contacts. She has no history of smoking cigarettes, IV drug or alcohol abuse. She only uses albuterol for asthma. On physical exam, she had epigastric and RUQ tenderness without guarding or rebound. She did not have hepatospleomegally and heart, lung and skin findings were normal. On laboratory investigation, WBC 5.4, Hb 13.4, INR 1.1, albumin 3.6, direct bilirubin 0.2, total bilirubin 0.9, AST 21, ALT 19, Lipase 46, glucose 93. She was HIV negative. Blood cultures had no growth. CT scan showed 3 encapsulated collections with the dominant (2.0 × 4.4 × 4.9 cm) in the diaphragmatic surface at the medial left hepatic lobe. Patient had smaller collections previously, which were read as hematomas 1 month after her initial surgery. Further investigation revealed normal AFP and CEA, and mildly elevated ESR and CRP, 30 and 1.154, respectively. Patient had CT guided biopsy done. Pathology showed acute and chronic inflammation with foci of abscess formation. Gram stain and AFB was negative and no fungus was grown. Cultures grew Salmonella Group B. Patient was started on Ciprofloxacin based on sensitivity and for 2 weeks upon discharge. Pyogenic liver abscess due to Salmonella is relatively uncommon. This abscess may have developed in the setting of past biliary disease that was not properly treated.Figure: [1066] CT scan showing a left hepatic lobe abscess.