Document Type
Event
Location
New Orleans, Louisiana
Event Website
https://www.medschool.lsuhsc.edu/DOM/Education/researchday/default.aspx
Start Date
4-2024 12:00 AM
End Date
4-2024 12:00 AM
Description
Pyogenic liver abscess as a late complication of hernia repair
• Carter Pesson, MD, MPH (LSUHSC) < cpesso@lsuhsc.edu > • Sidney Mejia, MD, MPH (LSUHSC) < smeji1@lsuhsc.edu > • Sanjay Kamboj, MD (LSUHSC) < skambo@lsuhsc.edu >
Clinical Vignette: An 81-year-old male with a past medical history significant for thoracic aortic aneurysm, HTN, enucleated right eye, and incarcerated inguinal hernia status post repair presented to the emergency department with progressive weakness associated with subjective fever, chills, and unintentional weight loss. On exam, he had epigastric abdominal tenderness overlying a palpable, immobile mass measuring approximately 3 cm, circumscribed with visible vasculature surrounding the tissue, along with 1+ pitting edema to bilateral lower extremities that extended to his ankles. CTA of his chest, abdomen, and pelvis demonstrated stable aortic aneurysms; however, he was found to have a cluster of rim-enhancing hypodense lesions in the left hepatic lobe, which were exophytic, and extended to the anterior abdominal wall in the epigastric region. An infectious and malignant workup was initiated at that time, demonstrating bacteremia by Streptococcus intermedius. He was initially started on Vancomycin and Zosyn for broad spectrum coverage, which was subsequently deescalated to ceftriaxone and metronidazole based on culture sensitivities. He tolerated liver and psoas abscess drainage with interventional radiology. A biopsy was completed of the abdominal abscess by interventional radiology, which was consistent in growing out Streptococcus intermedius and did not demonstrate any evidence of underlying malignancy. He completed 3 weeks of ceftriaxone and metronidazole outpatient with resolution of symptoms. He tolerated repeat MRI that demonstrated complete resolution of the hepatic abscesses and is currently stable off antibiotics. Discussion/Conclusion: Pyogenic liver abscesses, especially those caused by Streptococcus intermedius, are a documented sequalae of diverticular and periodontal disease, but less often seen in the setting of surgical history. With nonspecific symptoms, slow growth rate, and association with immunocompromised states, this pathology should be considered in differential diagnoses of nonspecific B symptoms. This case demonstrates that in the setting of recent abdominopelvic surgery and concurrent, slowly progressive symptoms of weakness and B symptoms, infectious processes should be considered in the differential diagnosis. Pyogenic liver abscesses, especially those caused by Streptococcus intermedius, have been noted to cause this constellation of symptoms. Early recognition and treatment of this infection early in the disease course prevented further infectious spread, thus highlighting the need for early consideration in future cases.
Recommended Citation
Pesson, Carter, "Pyogenic liver abscess as a late complication of hernia repair" (2024). Medicine Research Day. 48.
https://digitalscholar.lsuhsc.edu/mrd/2024mrd/mrdposters/48
Pyogenic liver abscess as a late complication of hernia repair
New Orleans, Louisiana
Pyogenic liver abscess as a late complication of hernia repair
• Carter Pesson, MD, MPH (LSUHSC) < cpesso@lsuhsc.edu > • Sidney Mejia, MD, MPH (LSUHSC) < smeji1@lsuhsc.edu > • Sanjay Kamboj, MD (LSUHSC) < skambo@lsuhsc.edu >
Clinical Vignette: An 81-year-old male with a past medical history significant for thoracic aortic aneurysm, HTN, enucleated right eye, and incarcerated inguinal hernia status post repair presented to the emergency department with progressive weakness associated with subjective fever, chills, and unintentional weight loss. On exam, he had epigastric abdominal tenderness overlying a palpable, immobile mass measuring approximately 3 cm, circumscribed with visible vasculature surrounding the tissue, along with 1+ pitting edema to bilateral lower extremities that extended to his ankles. CTA of his chest, abdomen, and pelvis demonstrated stable aortic aneurysms; however, he was found to have a cluster of rim-enhancing hypodense lesions in the left hepatic lobe, which were exophytic, and extended to the anterior abdominal wall in the epigastric region. An infectious and malignant workup was initiated at that time, demonstrating bacteremia by Streptococcus intermedius. He was initially started on Vancomycin and Zosyn for broad spectrum coverage, which was subsequently deescalated to ceftriaxone and metronidazole based on culture sensitivities. He tolerated liver and psoas abscess drainage with interventional radiology. A biopsy was completed of the abdominal abscess by interventional radiology, which was consistent in growing out Streptococcus intermedius and did not demonstrate any evidence of underlying malignancy. He completed 3 weeks of ceftriaxone and metronidazole outpatient with resolution of symptoms. He tolerated repeat MRI that demonstrated complete resolution of the hepatic abscesses and is currently stable off antibiotics. Discussion/Conclusion: Pyogenic liver abscesses, especially those caused by Streptococcus intermedius, are a documented sequalae of diverticular and periodontal disease, but less often seen in the setting of surgical history. With nonspecific symptoms, slow growth rate, and association with immunocompromised states, this pathology should be considered in differential diagnoses of nonspecific B symptoms. This case demonstrates that in the setting of recent abdominopelvic surgery and concurrent, slowly progressive symptoms of weakness and B symptoms, infectious processes should be considered in the differential diagnosis. Pyogenic liver abscesses, especially those caused by Streptococcus intermedius, have been noted to cause this constellation of symptoms. Early recognition and treatment of this infection early in the disease course prevented further infectious spread, thus highlighting the need for early consideration in future cases.
https://digitalscholar.lsuhsc.edu/mrd/2024mrd/mrdposters/48