The Case Files

Abstract

A 27-year-old woman with a history of recurrent urinary tract infections presented to the emergency department with right-sided flank pain and nausea. She denied fevers, chills, urinary symptoms, diarrhea, and constipation, though she did report some mild dyspnea and cough. She reported that she had had a normal spontaneous vaginal delivery of a healthy infant two weeks earlier. Pregnancy was complicated only by a urinary tract infection. The patient was febrile to 38.6°C. She did not have right costovertebral tenderness or right upper quadrant abdominal pain. Urinalysis was notable for positive nitrite, small leukocyte esterase, 5–10 white blood cells, 3–5 red blood cells, and positive bacteria. The urine culture ultimately grew 20,000 organisms of more than two organisms thought to be related to skin contamination. Serum laboratory testing was significant for a white blood cell count of 21,000 cells/μL, alkaline phosphatase 205 U/mL, total bilirubin 0.8 mg/dL, AST 37 U/L, and ALT 24 U/mL. The patient was given intravenous ceftriaxone in the ED for presumed pyelonephritis. One hour into her ED stay, she was noted to have tachypnea. Chest x-ray was obtained, and read as “probable mild blunting right costophrenic angle, perhaps atelectasis or small effusion. Fluid level right upper quadrant, likely within a loop of bowel or stomach.” A computed tomography scan of the chest, abdomen, and pelvis revealed several intrahepatic abscesses, with the largest measuring 8 x 10 x 11 cm in the posterior right lobe. The second largest was abutting the gallbladder with associated gallbladder wall thickening and pericholecystic fluid. The third and fourth abscesses in the tip of the right hepatic lobe were abutting the hepatic flexure and ascending colon with associated colon wall thickening. A fluid-filled borderline prominent ascending colon with moderate wall thickening was also seen. Surgery, OB/GYN, and interventional radiology were consulted, and the patient ultimately required drainage of the abscesses. Gram stain of the liver abscesses showed many polymorphonuclear cells, innumerable gram-positive rods, innumerable gram-positive cocci, many gram-negative rods, and a few gram-negative cocci. Anaerobic and aerobic cultures grew Escherichia coli, Bacteroides thetaiotaomicron-isolated, Peptoniphilus asaccharolyticus (previously Peptostreptococcus)-isolated, and Clostridium species-isolated.Coronal CT images showing multiple liver abscesses.Axial CT images showing large liver abscesses.This is the first known documented case of a liver abscess occurring in an otherwise healthy woman two weeks post-partum after an uncomplicated vaginal delivery. Liver abscesses can be seen in young women, but most have underlying risk factors such as diabetes mellitus, pancreatitis, appendicitis, cholelithiasis, gastrointestinal or hepatobiliary malignancy, gastrointestinal or pelvic infections, abdominal trauma, recent abdominal surgery, or liver transplantation. (Clin Infect Dis 2004;39[11]:1654; J Clin Gastroenterol 2005;39[7]:646; Current Medical Diagnosis & Treatment. New York: McGraw-Hill; 2012; Surg Clin North Am 2010;90[4]:679.) Liver abscesses are relatively rare, but they are still the most common type of visceral abscess (with an annual incidence of 3.6 cases per 100,000 population). (Am J Gastroenterol 2010;105[1]:117.) Liver abscesses can be caused by a bacteria, parasites, and fungi (Surg Clin North Am 2010;90[4]:679), but the most common organisms to cause them in North America are Klebsiella pneumoniae and Escherichia coli. (Clin Infect Dis 2004;39[11]:1654.) The pathogenesis of pyogenic liver abscess is multifactorial; the liver can be infected through the bile duct, the portal vein, the hepatic artery (secondary to bacteremia), or direct extension from any alternate underlying infection. Symptoms from a pyogenic liver abscess usually develop over days to weeks, and initially are characterized by malaise, anorexia, myalgias, arthralgias, and headache. (Surg Clin North Am 2010;90[4]:679.) Late findings more characteristic of pyogenic liver abscesses are fevers, chills, and right upper quadrant abdominal pain. (Surg Clin North Am 2010;90[4]:679.) Pyogenic liver abscesses are rare compared with pyelonephritis. (Am J Gastroenterol 2010;105[1]:117; Clin Infect Dis 2007;45[3]:273.) Clinical vigilance is important, or the diagnosis can easily be overlooked. Clinically, symptoms of pyogenic liver abscess are often nonspecific, but may include fever and abdominal pain. Jaundice may also be noted on physical exam in some cases. Laboratory abnormalities can include an elevated white blood cell count, erythrocyte sedimentation rate, and abnormal liver function tests. (Surg Clin North Am 2010;90[4]:679.) Blood cultures are positive in 50–100 percent of cases. Ultrasound, CT, or MRI can be used to diagnose pyogenic liver abscess. (Current Medical Diagnosis & Treatment. New York: McGraw-Hill; 2012; Surg Clin North Am 2010;90[4]:679.) The preferred treatment is percutaneous drainage of the abscess and several weeks of antibiotic therapy. (Clin Infect Dis 2004;39[11]:1654.) Pyelonephritis was initially suspected, but subtle clinical, laboratory, and radiological findings ultimately led to the correct diagnosis. The definitive mechanism by which the pyogenic liver abscess developed in our patient was never fully elucidated. Dr. Bremjitis a resident in internal medicine-family medicine at Eastern Virginia Medical School in Norfolk.Dr. Sheeleis an assistant professor and the fellowship director of international health and wilderness medicine in the department of emergency medicine at Eastern Virginia Medical School.