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Cryptogenic Pyogenic Liver Abscess Due to Fusobacterium Nucleatum: a Case Report

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Cryptogenic Pyogenic Liver Abscess Due to Fusobacterium Nucleatum: a Case Report Ryan Wilson, BSc, Ryan LeBlanc, BScPharm, ACPR, Abu A. Hamour, MBBS, MSc, FRCP(Edin), FRCP Cryptogenic pyogenic liver abscess due to Fusobacterium nucleatum: A case report Clinicians should consider the possibility of pyogenic liver abscess when patients present with fever, right upper quadrant pain, and shortness of breath. ABSTRACT: Pyogenic liver abscess- ormation of a pyogenic liver one case series identifying anaerobes es are relatively uncommon but po- abscess (PLA) is potentially in up to 45% of cases.11 Typically, sys- tentially life-threatening. Most in- F life-threatening, with an esti- temic F. nucleatum infections occur in fections that lead to an abscess are mat ed incidence rate of 2.3 cases immunocompromised individuals or associated with underlying biliary per 100 000 patients.1,2 Despite recent are of odontogenic origin.7-9,12 disease, or are due to hematogenous ad­­vances in the investigation and spread from a variety of nonbiliary management of such abscesses, the Case data sites. Although most infections are mortality rate still ranges from 2% to A 44-year-old woman presented to the polymicrobial, monomicrobial Fuso- 12%.3,4 Amebic liver abscess is the emergency room with a 6-day history bacterium nucleatum abscesses do most common form of liver abscess of fever, chills, rigor, vomiting, head- occur. These exceedingly rare mono- worldwide, whereas PLA is the most ache, and shortness of breath. She microbial infections typically occur common form in North America,5 had diffuse abdominal pain that had in immunocompromised individuals and is usually the result of polymi- become localized to the right upper or in the presence of periodontal crobial infection.6 It is believed that quadrant, and had progressed to being disease. A recent case involved a the introduction of pyogenic bacteria sharp and steady in nature and worse solitary pyogenic liver abscess due to the liver most often occurs during with inspiration. Her surgical history to F. nucleatum in an immunocom- an intra-abdominal infection, particu- included a total hysterectomy that had petent 44-year-old woman with no larly one involving biliary tract pa- been complicated by an Escherichia underlying risk factors. Despite the thology.1,3 Less often, bacteria spread coli bacteremia and sepsis secondary cryptogenic nature of the abscess, by way of the portal vein or hematog- to a surgical site infection. Her medi- the patient was treated successfully enously during systemic infection,1 cal history included chronic gastro- with percutaneous drainage and an- with periodontal disease being rec- esophageal reflux disease, which was tibiotics. ognized increasingly as a source of controlled with esomeprazole. Her pathogens in this setting.7-9 dental history was unremarkable. Although monomicrobial infec- After her 1991 hysterectomy and tions are rare, they do occur. A recent E. coli infection, the patient had suf- case involved Fusobacterium nuclea- fered a second episode of bacteremia tum, a nonmotile, gram-negative, anaerobic bacterium that normally Mr Wilson and Mr LeBlanc are medical inhabits the oropharynx and is a sig- students in the class of 2015 at the Uni- nificant contributor to the formation versity of British Columbia. Dr Hamour is of periodontal plaques.10 Anaerobic infectious disease internist and head of In- bacteria have long been known to ternal Medicine at the University Hospital This article has been peer reviewed. play a part in PLA formation, with of Northern British Columbia. 130 BC MEDICAL JOURNAL VOL. 56 NO. 3, APRIL 2014 www.bcmj.org Cryptogenic pyogenic liver abscess due to Fusobacterium nucleatum: A case report and sepsis in 2001 as a result of a Table. Results from initial laboratory tests. foodborne gastroenteritis. This sec- ond bacteremic episode is believed to Analyte Reference range Result have been precipitated, in part, by a WBC 4.0–10.0 × 109/L 17.3 (neutrophils 15.7) reduction in her immunity caused by an esomeprazole-related decrease in Hemoglobin 115–150 g/L 132 g/L gastric acidity. Platelets 160–380 × 109/L 226 × 109/L On presentation, the patient’s vital signs were recorded as tempera- Creatinine 45–84 umol/L 78 umol/L ture 39.5°C, heart rate 116 beats per Random glucose 3.6–6.1 mmol/L 5.4 mmol/L minute, blood pressure 92/62 mm Hg, oxygen saturation 98% on room Urea 2.0–8.2 mmol/L 7.4 mmol/L air, and respiratory rate 18 breaths AST (aspartate transaminase) < 32 IU/L 56 IU/L per minute. Physical examination ALT (alanine transaminase) 10–36 IU/L 69 IU/L revealed abdominal tenderness, worst in the right upper quadrant, with no GGT (gamma-glutamyl transferase) 5–36 IU/L 30 IU/L signs of peritonitis. She exhibited ALP (alkaline phosphatase) 42–98 U/L 61 U/L decreased air entry to both lung bas- es, and crackles were heard from the INR 0.9–1.2 1.4 lower left lobe. Abdominal and chest PTT (partial thromboplastin time) 26.6–41.4 seconds 47.9 seconds radiographs showed no abnormali- ties, ruling out a preliminary diagno- Bilirubin, direct–total < 5 µmol/L–< 18 µmol/L 6 µmol/L–14 µmol/L sis of pneumonia. Results from initial laboratory tests indicated infection ( Table ). Subsequently, gram-negative anaerobic bacilli identified as F. nucleatum were found in 2 of 2 vials of blood culture, and an abdominal ultrasound revealed a solitary liver mass ( Figure 1 ). A CT scan of the abdomen then confirmed the pres- ence of a 5 x 4.4 x 3.2–cm multilocu- lated mass in the anterior right lobe of the liver ( Figure 2 ). CT-guided per- cutaneous drainage was performed with direct aspiration of the abscess, which yielded thick purulent mate- rial. Laboratory examination of the aspirate fl uid revealed polymorpho- nuclear leukocytes and erythrocytes, but gram-stain and culture results were negative. Initially, the patient was empiri- cally treated with imipenem (500 mg by IV every 6 hours) and metronida- zole (500 mg by IV every 8 hours), but she was eventually switched to cefotaxime (2 g by IV every 8 hours) and metronidazole (500 mg by IV every 8 hours). The patient improved Figure 1. Ultrasound image of the liver showing solitary, largely hypoechoic mass (arrows). BC MEDICAL JOURNAL VOL. 56 NO. 3, APRIL 2014 www.bcmj.org 131 Cryptogenic pyogenic liver abscess due to Fusobacterium nucleatum: A case report creatic disease, diverticular disease, immunocompromised status, dia- betes mellitus, current malignancy, alcoholism, liver transplantation, and rheumatological disease such as rheu- matoid arthritis and systemic lupus erythematosus.2,9,12 Additionally, periodontal disease and recent dental manipulation have been recognized increasingly as risk factors for PLA.7-9 Several pathogens may cause a pyo- genic liver abscess, with Klebsiella pneumoniae, E. coli, and Streptococ- cus spp. being the most common in humans.2,8 F. nucleatum is a relatively uncommon bacterium in this setting, and is typically found only in cases of 13 Figure 2. CT scan of abdomen showing large multiloculated mass in anterior right lobe of periodontal disease. A case review the liver (arrow). published in 2008 by Kajiya and col- leagues identifi ed 13 described cases of PLA due to F. nucleatum.9 Since that time two more cases have been described.8,14 Of these 15 total cases, only four patients had documented immunocompetence, and of these four only one patient had no history of dental disease, but did interestingly present with a tonsil infection.15 The most common site of PLA (72% of cases) is the anterior right lobe of the liver, likely because of the site’s good vascular supply.14,16 However, it is diffi cult to attribute a source from infection based on its location within the liver. It is known that abscesses from a hematogenous seeding mechanism typically result in Figure 3. Follow-up MRI scan of abdomen following completion of antimicrobial therapy multiple lesions rather than a solitary showing resolution of the abscess. lesion.16 Although it would be highly unlikely for a liver to have been seed- on this regimen and after 13 days Discussion ed from remote bacteremic episodes, she was discharged on ceftriaxone The patient described here had no a history of multiple gram-negative (2 g by IV once daily) and metroni- recognized immunodefi ciency and no bacteremic episodes may increase dazole (500 mg P.O. 3 times daily) evidence of either dental or pharyn- susceptibility to recurrent bacteremia. for 5 weeks. Following completion geal pathology. This apparent lack of A case series in 1994 by Maslow and of 6 weeks of antibiotic therapy the risk factors raises questions about the colleagues looking at recurrent E. coli patient remained well and a follow-up true cause of the abscess. bacteremia found that all the patients MRI scan of the liver showed com- There are several risk factors for studied had “one or more identifi- plete resolution of the hepatic abscess developing pyogenic liver abscesses, able defects in local or systemic host ( Figure 3 ). including hepatobiliary disease, pan- defense mechanisms.”17 132 BC MEDICAL JOURNAL VOL. 56 NO. 3, APRIL 2014 www.bcmj.org Cryptogenic pyogenic liver abscess due to Fusobacterium nucleatum: A case report Currently, the results of history are essential.6 Risk factors for mor- humoral, and complement function taking, physical examination, labora- tality include an abscess greater than could be informative. Despite the tory tests, and imaging studies are the 5 cm in size, anaerobic infection, cryptogenic nature of the abscess, we mainstay for diagnosis of PLA. The and the need for open surgical drain- believe the F. nucleatum likely origi- clinical presentation of the patient age.21-23 Treatment consists of abscess nated in the oropharyngeal cavity.
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