Hepatic Abscess: Case Report And Review
A 35-year old male presents to the emergency department (ED) with what he describes as right-sided upper back and flank pain, which he attributes to a “cupping” procedure the day prior. The cupping procedure is an alternative medicine practice that uses local suction to theoretically stimulate blood flow and promote healing. He had no previous issues with the procedure. On further history he reported having had approximately 6 weeks of intermittent fevers, cough, anorexia and general malaise. He had seen multiple naturopathic physicians for these complaints, before an urgent care visit one week earlier. At that time, he had been started on azithromycin and doxycycline for a presumptive diagnosis of pneumonia. In the interim week he reported an improvement in his febrile symptoms and overall well-being. He was an otherwise healthy heterosexual male, without drug use or travel outside the country. He had no known sick contacts.\nOn physical examination his vital signs included a blood pressure of 116/75 mmHg, a heart rate of 119 beats per minute, and a respiratory rate of 20 breaths per minute. His temperature in the ED was 36.2°C. Oxygen (O2) saturation was 97% on room air. The patient was alert, and appropriate with no signs of respiratory distress. Pertinent physical findings revealed typical, non-tender cupping marks on his back. More concerning was an absence of breath sounds on the right side of the chest on auscultation. His abdomen was soft and non-tender. The remainder of the physical examination was non-contributory.\nThe initial diagnostic test ordered was a chest radiograph, which showed 80% opacification of the right hemithorax, consistent with pneumonia and associated parapneumonic effusion seen in . A bedside ultrasound was subsequently performed in the ED, initially in order to examine the size of the pleural effusion in which a startling discovery was made. The image of the right upper quadrant is shown in and corresponding .\nAs a result of these abscess findings, the patient underwent a computed tomography (CT) of the chest, abdomen and pelvis to determine the extent of the pulmonary and hepatic disease.\nA consultative ultrasound confirms a 10.2 × 8.9 × 12.6 cm abscess in the right lobe of the liver and can be seen in Figure 5. Bloodwork sent after initial examination returned showing a white blood cell count of 25×109/L, creatinine of 92 mmol/L, and lactate of 3.5 mmol/L. Liver transaminases and international normalized ratio were within normal limits. While in the ED his O2 requirements increased to 4L and his blood pressure started to trend down. It dropped to a low of 90/60 with a HR of 108. The patient was treated in the ED with 2 liters of normal saline and started on levofloxacin, vancomycin and piperacillin/tazobactam.\nA thoracocentesis was performed showing 33,688 u/L white blood cells with 93% neutrophils although an initial gram stain was negative. Antibiotics were switched to ceftriaxone and metronidazole after infectious disease consultation. The patient was admitted to the surgical intensive care unit where he underwent central line placement and an interventional radiology guided liver abscess drainage with percutaneous drain placement, and tube thoracostomy. He later underwent a assisted thorascopic surgery (VATS) decortication procedure where a diaphragmatic defect was found, continuous with the hepatic abscess cavity. No microorganisms were found on gram stain, or any subsequent cultures.\nFollowing the VATS procedure the patient made a quick recovery and was discharged from hospital. He continues to recover well. He spent 1 month on intravenous (IV) ceftriaxone and metronidazole administered through a peripherally inserted central catheter line before having the antibiotics discontinued. The etiology of this culture negative abscess has never been identified .