Case Presentation:
47 year old female with a past medical history of hypertension presented to the emergency room with two days of right upper quadrant pain and a fever to 102F. For several months prior, she complained of bloating, intermittent diarrhea and diffuse abdominal pain that now localized. Her social history was positive for recent travel to Panama three months prior to presentation. In the emergency room, her vitals were significant for tachycardia to 104, respiratory rate of 22 with right upper quadrant pain on palpation without rebound. Her laboratory values were significant for a leukocytosis to 15.6 K/ul. A CT of the abdomen/pelvis was performed that demonstrated a large left hepatic lobe abscess that was approximately 8cm x 8cm as well as mild haziness of fat surrounding the rectum possibly indicating proctitis. She was empirically started on ciprofloxacin and metronidazole and admitted to the medicine service for further care where the likely etiology of her abscess was presumed Entamoeba Histolytica. Multiple consultants evaluated the patient and the initial plan was conservative management with antibiotics. However, as the patient’s symptoms didn’t improve and more guidelines were researched, interventional radiology (IR) was consulted for aspiration and percutaneous drainage placement. During the procedure, aspiration was attempted but resulted in no aspirate as no fluid was present. Instead, necrotic tissue was noted and therefore biopsies of the necrotic and solid appearing areas in the liver were sent for culture and cytology. The final pathology results of the liver revealed a predominately necrotic neoplasm compatible with a neuroendocrine tumor of small or large intestine primary. She was discharged home off antibiotics with oncology follow-up.
Discussion:
Liver abscesses are rare but when present, can be a cause of morbidity and mortality. Pyogenic, amebic and fungal are the most common etiologies respectively. In this case, given the patient’s travel history, abdominal pain, proctitis and fevers, the diagnosis of highest probability was an amebic abscess. The consultants on the case were initially wary of advocating for the drainage of the abscess, as there was a concern that the origin of the abscess was Echinococcus and aspiration of Echinococcus can result in anaphylaxis and spread of the infection. Also, per literature review, there were confounding recommendations suggesting medical management alone by some and drainage by others. As no uniform recommendation were present, after careful clinical evaluation and discovery of a review article that suggested that abscesses over 5cm, even if amoebic in origin, respond better with drainage, IR agreed to do the procedure. This case demonstrates the importance of drainage, as radiological imaging can be misleading. This patient ultimately was diagnosed with a rare neuroendocrine tumor after the IR guided procedure only yielded necrotic tissue. She was subsequently appropriately diagnosed and treated, which would have been delayed or not happened had there been no sampling of her hepatic abscess.
Conclusions:
CT imaging can be highly suggestive of hepatic abscess, but this case underscores the fact that imaging alone is not 100% specific. Clinicians should maintain an high clinical suspicion for abscesses greater then 5 cm and consider aspiration and tissue biopsy to confirm diagnosis.
