Streptococcal Hepatic Abscess: A Rare Complication of Severe Necrotizing Pancreatitis

Abstract

A 60-year-old female was admitted with severe pancreatitis of unknown etiology, with symptoms of epigastric abdominal pain, and nausea with vomiting. Contrast enhanced computed tomography (CT) scan showed large areas of non-enhancement of the pancreatic body, and extensive peripancreatic free fluid and stranding in the regions of the pancreatic head and tail consistent with acute necrotizing pancreatitis. She was also noted to have non-occluding thrombi of the superior mesenteric vein that extended into the portal vein and was started on long-term anticoagulation treatment with oral warfarin. Her clinical course was complicated by the development of a large pancreatic pseudocyst (11 x 13 x 23 cm on CT) that was managed successfully by endoscopic cystogastrostomy [Figure 1]. Unfortunately, after initial good recovery, she was hospitalized 3 months later with ascites and failure to thrive. A repeat contrast enhanced CT scan showed a large multi-loculated 7.4 x 7.8 x 9.2 cm mass in the liver involving caudate lobe, and right lobe of liver concerning for hepatocellular carcinoma [Figure 2]. On endoscopic ultrasound a large hypoechoic, heterogeneous mass was noted in the liver. Fine needle aspiration using a 25G needle was performed and on site evaluation by cytopathology showed extensive necrosis and acute inflammation concerning for hepatic abscess. Additional FNA was performed for culture and sensitivity that revealed gram-positive bacteria in clusters (Group F streptococcus). Patient was treated with longterm intravenous vancomycin. She had near complete resolution of liver abscess at 6-week follow-up. Pancreatic pseudocyst and splenic vein thrombosis are the known complications of severe pancreatitis. However, the development of a liver abscess possibly following pylephlebitis in the background setting of acute necrotizing pancreatitis is a rare entity with only a few cases reported in the literature. Our patient developed severe hepatic abscess and ascites mimicking hepatocellular cancer. Likely etiology of this abscess was superior mesenteric vein and portal vein thrombosis. This case highlights the rare complication of severe necrotizing pancreatitis and role of EUS guided tissue acquisition in diagnosis and management of hepatic abscess.Figure 1Figure 2