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Fusobacterium nucleatum: a rare cause of pyogenic liver abscess.

Nagpal SJ, Mukhija D, Patel P - Springerplus (2015)

Bottom Line: Rarely, mono-microbial infections may occur, typically in immunocompromised individuals.We report the unusual case of a 69 year-old immunocompetent female who developed a pyogenic liver abscess due to Fusobacterium nucleatum infection, likely from a dental source.Poor oropharyngeal hygiene seems to have a major role in infection from this organism and therefore F. nucleatum should be considered as a differential for causes of pyogenic liver abscess in such patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195 USA.

ABSTRACT
While pyogenic liver abscesses are uncommon, they are associated with significant mortality and morbidity. Most pyogenic liver abscesses are polymicrobial and are caused by enteric bacteria and anaerobes. Rarely, mono-microbial infections may occur, typically in immunocompromised individuals. We report the unusual case of a 69 year-old immunocompetent female who developed a pyogenic liver abscess due to Fusobacterium nucleatum infection, likely from a dental source. Poor oropharyngeal hygiene seems to have a major role in infection from this organism and therefore F. nucleatum should be considered as a differential for causes of pyogenic liver abscess in such patients. Drainage of the abscess and antibiotic therapy are the mainstays of therapy.

No MeSH data available.


Related in: MedlinePlus

Abdominal computerized tomography (CT) showing a multiseptated thick walled mass in the right hepatic lobe.
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Fig1: Abdominal computerized tomography (CT) showing a multiseptated thick walled mass in the right hepatic lobe.

Mentions: On presentation, her vitals showed a temperature of 38.1°C (100.6°F), heart rate 117 beats per minute, blood pressure 98/62 and an oxygen saturation of 96% on room air with a respiratory rate of 15 breaths per minute. Physical exam revealed poor dental hygiene and tenderness in the abdomen, which was worst in the RUQ. Murphy sign was negative and there were no signs of peritonitis. Labs revealed significant leucocytosis (22.82 × 103/µl) with 94.2% neutrophils. Liver function tests revealed a normal AST and ALT (25 and 22 U/L, respectively) and a normal total bilirubin (1.3 mg/dL). Ultrasound imaging of the right upper quadrant (RUQ), done to investigate the pain, revealed a 9 × 7 × 7 cm hypoechoic density in the right hepatic lobe. Due to concern for possible infection, she was started on broad spectrum antibiotics, Vancomycin 1.5 g daily and Meropenem 500 mg bid. Abdominal computerized tomography (CT) showed a multiseptated thick walled mass in the right hepatic lobe (Figure 1). The CT did not show any other potential sources of infection or malignancy and the previously known pancreatic and renal cysts were stable in size and appearance. Vancomycin was stopped by Day 3 of admission due to low concern for MRSA infection. She underwent CT-guided pigtail drain placement which revealed thick, purulent material. Microscopic examination of the abscess fluid revealed polymorphonuclear leucocytes but gram stain was negative. However, cultures from the drain fluid as well as admission blood cultures (2 out of 2 each) revealed Fusobacterium nucleatum. X-rays of the teeth showed evidence of moderate to severe chronic periodontitis for which she underwent extraction of all remaining teeth. She also underwent a colonoscopy to rule out occult colonic malignancy as the incidence of PLA is disproportionately higher in patients with occult colonic malignancy (Qu et al. 2012; Kao et al. 2012; Huang et al. 2012; Lai et al. 2014). The colonoscopy only showed diverticulosis. She improved remarkably and was eventually discharged home on intravenous Ertapenem (chosen over penicillins/cephalosporins due to her allergies) to complete a total of 2 weeks of intravenous antibiotic therapy, followed by a 4 week suppressive regimen of oral Penicillin VK. A repeat CT at 4 months post discharge (Figure 2) showed complete resolution of the hepatic lesion.Figure 1


Fusobacterium nucleatum: a rare cause of pyogenic liver abscess.

Nagpal SJ, Mukhija D, Patel P - Springerplus (2015)

Abdominal computerized tomography (CT) showing a multiseptated thick walled mass in the right hepatic lobe.
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4472653&req=5

Fig1: Abdominal computerized tomography (CT) showing a multiseptated thick walled mass in the right hepatic lobe.
Mentions: On presentation, her vitals showed a temperature of 38.1°C (100.6°F), heart rate 117 beats per minute, blood pressure 98/62 and an oxygen saturation of 96% on room air with a respiratory rate of 15 breaths per minute. Physical exam revealed poor dental hygiene and tenderness in the abdomen, which was worst in the RUQ. Murphy sign was negative and there were no signs of peritonitis. Labs revealed significant leucocytosis (22.82 × 103/µl) with 94.2% neutrophils. Liver function tests revealed a normal AST and ALT (25 and 22 U/L, respectively) and a normal total bilirubin (1.3 mg/dL). Ultrasound imaging of the right upper quadrant (RUQ), done to investigate the pain, revealed a 9 × 7 × 7 cm hypoechoic density in the right hepatic lobe. Due to concern for possible infection, she was started on broad spectrum antibiotics, Vancomycin 1.5 g daily and Meropenem 500 mg bid. Abdominal computerized tomography (CT) showed a multiseptated thick walled mass in the right hepatic lobe (Figure 1). The CT did not show any other potential sources of infection or malignancy and the previously known pancreatic and renal cysts were stable in size and appearance. Vancomycin was stopped by Day 3 of admission due to low concern for MRSA infection. She underwent CT-guided pigtail drain placement which revealed thick, purulent material. Microscopic examination of the abscess fluid revealed polymorphonuclear leucocytes but gram stain was negative. However, cultures from the drain fluid as well as admission blood cultures (2 out of 2 each) revealed Fusobacterium nucleatum. X-rays of the teeth showed evidence of moderate to severe chronic periodontitis for which she underwent extraction of all remaining teeth. She also underwent a colonoscopy to rule out occult colonic malignancy as the incidence of PLA is disproportionately higher in patients with occult colonic malignancy (Qu et al. 2012; Kao et al. 2012; Huang et al. 2012; Lai et al. 2014). The colonoscopy only showed diverticulosis. She improved remarkably and was eventually discharged home on intravenous Ertapenem (chosen over penicillins/cephalosporins due to her allergies) to complete a total of 2 weeks of intravenous antibiotic therapy, followed by a 4 week suppressive regimen of oral Penicillin VK. A repeat CT at 4 months post discharge (Figure 2) showed complete resolution of the hepatic lesion.Figure 1

Bottom Line: Rarely, mono-microbial infections may occur, typically in immunocompromised individuals.We report the unusual case of a 69 year-old immunocompetent female who developed a pyogenic liver abscess due to Fusobacterium nucleatum infection, likely from a dental source.Poor oropharyngeal hygiene seems to have a major role in infection from this organism and therefore F. nucleatum should be considered as a differential for causes of pyogenic liver abscess in such patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195 USA.

ABSTRACT
While pyogenic liver abscesses are uncommon, they are associated with significant mortality and morbidity. Most pyogenic liver abscesses are polymicrobial and are caused by enteric bacteria and anaerobes. Rarely, mono-microbial infections may occur, typically in immunocompromised individuals. We report the unusual case of a 69 year-old immunocompetent female who developed a pyogenic liver abscess due to Fusobacterium nucleatum infection, likely from a dental source. Poor oropharyngeal hygiene seems to have a major role in infection from this organism and therefore F. nucleatum should be considered as a differential for causes of pyogenic liver abscess in such patients. Drainage of the abscess and antibiotic therapy are the mainstays of therapy.

No MeSH data available.


Related in: MedlinePlus