ID: 29: INVASIVE LIVER ABSCESS SYNDROME IN NORTH AMERICA

Case presentation This is a 25 years old Pilipino male with no past medical history who presented with fever, rigors, fatigue and night sweats for 3 days. His symptoms progressively getting worse which made him seek medical attention. Patient travelled to Philippines five months ago which he stayed for a month. Upon presentation, patient was febrile with Temp 104 F and tachycardic 139 BPM, BP113/76. He appeared to be diaphoretic and tachypnic on physical exam. Abdomen was soft and non-tender, no hepatomegaly or splenomegaly on palpation. Pertinent laboratory findings included leukocytosis of 14,000 and bandemia 12, lactate of 3.6, Liver function tests – AST 62/ALT 61/ ALK 52 GGT 48 LDH 347 Total bilirubin 2.5 and direct Bilirubin 1.6 – Hepatitis serology revealed immunity against Hepatitis B (HBV). Coagulation panel and renal function were normal. Abdominal imaging revealed diffuse hepatic changes suggestive of cirrhosis and complex avascular slightly lobulated hypoechoic mass with mild posterior enhancement measuring 7.2×6.8 cm noted in the anteromedial portion of posterior segment of the right lobe (figure 1A and B). Further tests including HIV testing, urine analysis, blood and urine cultures, Echinococcosis and Amoebic serology were none revealing. Empirical broad spectrum antibiotics with 3rd generation cephalosporin and metronidazole for possible amoebic verus pyogenic liver abscess. After 3–4 days from admission date, he developed persistent rigors, tachycardia, and appeared to have respiratory distress which required an urgent intubation for acute respiratory failure and transferred to ICU. Urgent drainage attempted for pyogenic liver abscess. Abscess fluid culture was positive for Klebsiella pneumonia. Patient received an intravenous ceftriaxone 2 gm daily with continuous Jackson-Pratt liver drain suction for 3–4 weeks which was curative with resolution and decrease in the size of liver abscess on repeat imaging (figure 1c). Discussion Klebsiella pneumoniae, a member of the Enterobacteriaceae family, is a pathogen with worldwide distribution. Most community-acquired Klebsilla pneumoniae infections cause pneumonia or urinary tract infections. Invasive liver abscess syndrome is very rare in western countries. For the past 2 decades, a distinct clinical syndrome has been emerging in Southeast Asia that is characterized by bacteremia, liver abscesses, and metastatic infections. In the past decade, few patients were diagnosed as having a liver abscess caused by K pneumoniae in two case series in the USA. Most community-acquired Klebsilla pneumoniae infections cause pneumonia or urinary tract infections. Invasive liver abscess syndrome is very rare in western countries. Clinicians should be aware about invasive klebsiella pneumonia liver abscess especially in patients with Asian background presented with liver abscess failed the treatment with antibiotics. Treatment of invasive klebsiella pneumonia liver abscess requires dual approach medical and surgical as we approached our patient which he subsequently improved after CT-guided liver abscess drainage and four weeks of antibiotics therapy.