Severe systemic sepsis due to pyogenic liver abscess

Abstract

Pyogenic liver abscess is a potentially life-threatening disease with a reported mortality of up to 30–50%. Escherichia coli and Klebsiella pneumoniae (Kp) are the most important pathogens for pyogenic liver abscess. Modern imaging techniques such as ultrasonography (USG) and computed tomography (CT) are used for diagnosis and treatment. Treatment with intravenous (iv) antibiotics and application of catheter drainage (under the guidance of imaging techniques) are the principal therapies. Surgical intervention is indicated if failure of medical treatment and rupture of abscess are noted [1, 2] Herein, we present the case of a pyogenic liver abscess due to Kp in a diabetic man in our intensive care unit (ICU). A 60-year-old man with a history of diabetes mellitus was referred to our ICU with deterioration of his general condition. He was treated for suspected urinary tract infection in another hospital for several days, but the symptoms were not resolved. On admission, he was septic with a clouding of consciousness. On examination, he had tachypnea, tachycardia, hypoxemia, fever and impaired peripheral circulation with acral cyanosis. He was hypotensive with a systolic blood pressure of 70 mmHg and responded to fluid resuscitation, but subsequently required ventilatory support for respiratory deterioration. He had acute renal impairment requiring hemodialysis, and disseminated intravascular coagulopathy (DIC), secondary to sepsis. Laboratory tests also revealed impaired liver and renal function tests, leukocytosis, high erythrocyte sedimentation rate and an elevated C reactive protein (CRP) level. Chest X-ray showed consolidation on bilateral lower zones of the lungs. Antibiotherapy was initiated with iv administration of imipenem and ciprofloxacin after blood, urine, and tracheal aspirate cultures were obtained. A bedside abdominal USG showed a thick walled cystic lesion, 7 cm in diameter, in the right lobe of the liver and it was interpreted as liver abscess. Cranial, thoracal and abdominal CTs were performed subsequently. Cranial CT was normal. Thoracal CT revealed multiple cavitating nodules in lung parenchyma, pneumonic consolidations on bilateral basal segments and bilateral minimal pleural effusions (accepted as spread of infection to the lung via septic emboli). Abdominal CT revealed an abscess (7 cm 9 5 cm 9 5 cm) in the right lobe of the liver (Fig. 1). Percutaneous drainage of the liver abscess with the guidance of abdominal USG was performed on the fourth day after hospitalization. The thick pus was drained with needle aspiration and the drainage catheter was left in situ and attached to an external drainage bag. Cultures of the liver aspirate eventually grew Kp. Kp was also found in one set of blood cultures performed on admission. Intravenous antibiotics were not changed according to antimicrobial sensitivities. Despite continued treatment with appropriate antibiotics and drainage, he worsened and died because of disseminated Kp infection and sepsis on the seventh day after hospitalization. Most pyogenic liver abscesses are secondary to infection originating in the abdomen. Cholangitis due to stones or G. Aygencel (&) Division of Critical Care Medicine, Department of Internal Medicine, Gazi University Faculty of Medicine, Besevler, 06510 Ankara, Turkey e-mail: aygencel@hotmail.com