Sepsis of Unknown Origin Secondary to Liver Abscess Caused by Fish Bone Migration

Abstract

The authors present the case of a woman of 80 years of age, without relevant medical history, which presented to the emergency department for fever (38-39°C), chills, nausea and vomiting, and persistent pain in the right hypochondrium lasting for two days. Initial clinical assessment revealed hypotension, hypoxemia (pO2 < 70mmHg), slight leukocytosis, CRP 176mg/L and increased lactates (3.0mmol) and the imaging studies (chest X-ray and abdominal CT) showed no change. Then the patient was hospitalized in intermediate care unit where she was started on antibiotics with a diagnosis of sepsis of unknown origin. Two days after, the patient was clinically better but maintained abdominal complaints and so it was performed a new abdominal CT scan where we were able to identify a linear foreign body with approximately 30mm perforating the intestinal wall at the level of the pylorus, contacting with the hepatic parenchyma where a multiloculated abscess with 44mm was seen (figure 1 [arrow]). After further conversation with the patient, it was found to be of a fishbone ingested days before. Consequently, an upper endoscopy was performed where it was found a swollen area in the antero-superior duodenal bulb wall with a central fistulous opening (figure 2). After discussion with the surgical team it was decided to maintain a conservative strategy (antibiotics plus imaging surveillance). Once there was gradual improvement of the clinical picture, the patient was transferred to the surgery ward and then discharged to outpatient consultation.Figure 1Figure 2A myriad of ingested sharp-pointed objects have been described and not always the patients are aware of foreign body ingestion, and in these cases the diagnosis is only made on the occurrence of complications, such as in the reported case. Cases of hepatic abscess due to fish bone penetration are very rare and may be fatal. Since the first reported case, treatments usually include drainage of the abscess, removal of the foreign body, and administration of appropriate antibiotics. Surgery is considered the treatment of choice in current clinical practice, but when the diagnosis is not initially suspected, and if the patient shows clinically improvement, a conservative approach can be attempted. In this case, once the patient was better under empirical antibiotics we preferred not to submit the patient to a surgical procedure. So we suggest that medical approaches could be attempted first in such cases.