Author Affiliations: Department of Internal Medicine (Tulachan SS, Wilkins CE and Marnejon TP), Department of Infectious Disease (Cutrona AF), and Department of Research (Gemmel D), St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH 44501, USA

Corresponding Author: Sidhartha S Tulachan, MD, PhD, Department of Internal Medicine, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH 44501, USA (Tel: 1-330-480-7643; Fax: 1-330-480-3777; Email: sstulachan@gmail.com)

 

© 2013, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(13)60069-7

 

 

Contributors: TSS wrote the first draft of this report. All authors contributed to the intellectual context and approved the final version. TSS is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

BACKGROUND:Hepatic abscess secondary to Salmonella is extremely rare in the United States and other Western countries.

 

METHODS: A 43-year-old Caucasian man, with a history of chronic alcohol abuse, was admitted to the hospital for intermittent abdominal pain, fever and diarrhea. Clinical, radiological and laboratory results were analyzed. Medical literature in PubMed pertaining to similar cases was reviewed.

 

RESULTS:Stool culture was positive for Salmonella serotype B and a CT scan of the abdomen with contrast was consistent with a solitary hepatic abscess. Appropriate intravenous antibiotics followed by oral maintenance therapy for six weeks resulted in a complete clinical recovery and radiographic resolution.

 

CONCLUSIONS: The cause of Salmonella hepatic abscess in our patient was most likely associated with decreased mucosal resistance to the bacteria, seeding of infection via transient portal bacteremia and loss of host immunity. Our case highlights the fact that appropriate antibiotic alone is sufficient in the management of a solitary hepatic abscess less than 3-5 cm.

 

(Hepatobiliary Pancreat Dis Int 2013;12:440-442)

 

KEY WORDS: hepatic abscess; Salmonella; alcoholic; hypochlorhydria; antibiotics

Salmonella is ubiquitous and is a worldwide public health problem. The majority of persons who ingest Salmonella never develop an illness. Salmonella infection manifests as various clinical syndromes. The disease severity varies from mild self-limiting gastroenteritis to severe septicemia and focal abscess formation, the latter being a major cause of morbidity and mortality.^[1] In this report, we discuss a case of a solitary right lobe hepatic abscess secondary to Salmonella serotype B infection, managed by antibiotics alone.

 

 

A 43-year-old Caucasian man with a history of alcohol abuse, presented with sudden onset of severe abdominal pain and diarrhea. The abdominal pain was described as diffuse, crampy and intermittent in nature. The diarrhea occurred 8-10 times a day with watery, non-foul smelling stool. No mucus or blood was noted. Other associated symptoms included hand tremor, nausea, low-grade fever and chills. There was no history of sick contacts or recent travel. Other significant past medical history included gastric ulcer disease treated with chronic proton pump inhibitor therapy.

 

On examination the patient was anxious, agitated, diaphoretic and mildly dehydrated. Temperature was 37.6?��, pulse 87 per minute, respiration 26 per minute, and blood pressure 158/96 mmHg. There was no pallor or icterus. Considerable guarding was present on abdominal examination with tenderness in the epigastric and right upper quadrant regions, without rebound tenderness. The liver was palpable 4 cm below the costal margin. The remainder of the examination was unremarkable.

 

Initial laboratory studies showed normal renal and hepatic function. The hematological parameters revealed a white cell count of 10.4×10⁹/L with elevated absolute neutrophil count. Urine drug screening was positive for cocaine, benzodiazepines and opiates. Serum ethanol level was less than 10 mg/dL. The initial clinical impression was acute alcohol or opioid withdrawal and alcoholic gastritis. The patient was admitted and treated with intravenous fluids, thiamine, folic acid, clonidine and lorazepam. Stool work-up for ova and parasite, Clostridium difficle (C. diff) toxin and enteric pathogen, blood and urine cultures were performed. The stool was negative for C. diff, ova and parasites. Blood and urine cultures had no growth. An acute hepatitis panel and HIV-1/HIV-2 serology was also non reactive. Additional blood work revealed an elevated sedimentation rate of 47 mm/h and C-reactive protein of 21.2 mg/dL. CT scan of the abdomen with intravenous and oral contrast showed a mildly enlarged liver, a diffuse pattern of colitis involving the ascending and proximal transverse colon, and a 1.5×2.0 cm subtle low density lesion in the right lobe of the liver at the level of the gallbladder fossa consistent with a solitary hepatic abscess (Fig. A-C). Empiric intravenous cefepime and metronidazole were initiated.

 

Over the next two days, the clinical condition of the patient deteriorated. He remained febrile with a temperature of 39.1?��, persistent hepatic tenderness and diarrhea. Stool culture grew Salmonella serotype B. The antibiotics were changed to intravenous ciprofloxacin. The condition of the patient was improved, and he was discharged on the tenth day of admission, after a good clinical recovery. Oral ciprofloxacin was continued for a total of six weeks and the patient was scheduled to follow up in the outpatient clinic. A repeat abdominal CT after completion of antibiotic therapy showed a complete resolution of the previously described solitary hepatic abscess (Fig. D-F).

 

 

The three major forms of hepatic abscess, classified by etiology, are pyogenic, amebic, and fungal. The most common pathogens of the pyogenic hepatic abscesses are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci. The overall incidence of pyogenic hepatic abscess in the United States is 3.6 per 100 000 according to a population-based study.^[2] The most common infections are Streptococcus species (29.5%), Escherichia coli (18.1%) and polymicrobial (16.3%). However, the incidence of pyogenic hepatic abscess secondary to Salmonella is not known. A literature review utilizing a PubMed search yielded only 18 case reports in Western countries since 1952.^{[1, 3-6]}

 

Although the blood culture was negative in our patient, the diagnosis of Salmonella hepatic abscess was based on clinical symptoms, radiographic findings, positive stool culture and effective response to appropriate antimicrobial therapy. Previous studies have shown that concomitant bacteremia is found in only 33%-50% of patients with pyogenic hepatic abscess.^{[7, 8]} Moreover, Salmonellae bacteria are less frequently isolated from blood cultures or from focal extraintestinal sites.^{[5, 9, 10]} It is generally accepted that hepatic abscess is caused by Salmonella when CT image is compatible with hepatic abscess and Salmonella is isolated in stool culture. The most common site of hepatic abscess is the right lobe, and underlying pathology is frequently found in the region of portal drainage. The likely source of the hepatic abscess in our patient could therefore possibly be secondary to the seeding of infection from the large bowel via transient portal bacteremia.^[11]

 

Salmonella infection can involve any part of the gastrointestinal tract, but extraintestinal disease usually involves the hepatobiliary system and spleen. More than 2000 Salmonella serotypes have been described, but only a few serotypes are invasive and can cause extraintestinal diseases in humans.^[12] The virulence factor of Salmonella is based on genes that encode the polysaccharide portion of lipopolysaccharide (LPS) and flagellin. Based on the Kauffmann-White classification, serotypes A, B and D share a common trisaccharide backbone in LPS and are considered more virulent than others.^{[12, 13]} Similarly, a number of comorbid conditions are associated with a significantly higher risk of developing pyogenic hepatic abscess such as malignancy, sickle cell trait, liver cirrhosis, impaired bowel motility, and immunocompromized status namely HIV infection and diabetes mellitus.^{[5, 14, 15]} In our patient, the likely risk factors included hypochlorhydria due to chronic use of proton pump inhibitors, which can decrease the mucosal barrier against this pathogen^{[16, 17]} and chronic alcohol abuse, which can impair host immunity.^[18]

 

Different strategies have been proposed for the treatment of pyogenic hepatic abscesses depending on their initial size and location. Some authors^[19] suggest that abscesses less than 3 cm may be successfully treated with antibiotics alone, whereas others^[20] recommend a cutoff of less than 5 cm. Larger uniloculated abscessess should be treated with intravenous antibiotics and percutaneous drainage in the form of ultrasound guided needle aspiration or percutaneous catheter drainage. Surgical or laparoscopic drainage is recommended for large multi-loculated collections.^{[19, 20]} All reported Salmonella hepatic abscess cases were treated with antibiotics and either surgical or percutenous catheter drainage. Our case is the first reported case of Salmonella hepatic abscess, which was treated to complete resolution by antibiotics alone.

 

In summary, we described a case of a solitary hepatic abscess associated with Salmonella serotype B and illustrated that appropriate antibiotic therapy alone is effective for complete resolution of an abscess less than 3-5 cm.

 

 

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