Case Presentation: We present a case of a 63-year-old woman with hypertension and depression who was hospitalized following two weeks of chills and generalized abdominal pain. The patient denied history of HIV, hepatitis, or IV drug use. Initial workup showed white blood cell count elevation to 18 k/cumm (3.2-11.0 k/cumm) and CT of the abdomen showed a 7.6 x 6 cm septated cystic lesion with several smaller surrounding abscesses in the left lobe of the liver. Empiric antibiotic therapy was initiated with vancomycin and meropenem, followed by CT-guided percutaneous drain insertion into the largest intrahepatic abscess. However, the patient required revision of drain placement due to progressive abdominal distension and leukocytosis to greater than 33 k/cumm. Subsequently, the patient became encephalopathic and a CT of the head was obtained after the patient sustained a mechanical fall which demonstrated a loss of a grey-white matter differentiation in the right frontoparietal region. Follow up MRI of the brain with contrast revealed two abscesses along the right parietal vertex measuring 14 x 9 and 8 x 11 mm. Lumbar puncture did not identify a bacterial or viral source of infection, however, admission blood cultures grew Peptoniphilus asaccharolyticus. The patient completed an extended course of meropenem per the recommendations of Infectious Diseases. Clinically, the patient’s encephalopathy improved and was discharged on day 14 of admission with a five-week course of meropenem and follow-up surveillance imaging.
Discussion: Hepatic and brain abscesses are associated with high mortality. Hematogenous dissemination of bacteria is responsible for approximately a third of cases of brain abscess and immunosuppression is a key predisposing factor. In this case, the patient did not have a history of malignancy or transplantation, and HIV testing conducted during admission was negative. Underlying cardiac diseases such as endocarditis or congenital anomalies are common in hematogenous spread. Transesophageal echocardiogram did not show infective endocarditis and the patient had no congenital disease. Contiguous brain abscesses, which account for approximately half of all cases of brain abscesses, occur when pathogens spread directly to the brain through mechanisms such as trauma, surgery, or head and neck infections. In our patient, thorough physical examination did not demonstrate head and neck infection. Additionally, P. asaccharolyticus is uncommonly seen in cases of brain abscess with streptococcus species being the most common pathogen (34%), followed by staphylococcus species (18%), followed by enteric gram-negative species (15%). Hepatic abscess is also a rare condition and can be attributed to parasitic, fungal, or bacterial pathogens. In Western countries, approximately 80% of hepatic abscesses are bacterial and most frequently associated with hepatobiliary disease, spread contiguously in inflammatory processes, or superimposed infections on biliary cysts or tumors. Interestingly, none of these processes were discovered in this patient.
Conclusions: This case demonstrates a unique combination of hepatic and brain abscesses without obvious risk factors for either. It remains unclear what underlying factors contributed to the development of these abscesses, but fortunately, the patient responded well to antibiotics alone. This case demonstrates that surgical management may not be required if the patient is on an appropriate antibiotic regimen.
