Clostridium perfringens Hepatic Abscess Bubbles Up After Recent Chemotherapy

Abstract

INTRODUCTION: C. perfringens hepatic abscess is an exceedingly rare condition; only14 cases have been described in literature, the vast majority of which had been fatal. Previous case reports identified some common risk factors for developing a C. perfringens liver abscess: trauma or previous surgery in the area of abscess formation and chemotherapy. We present a case of a patient who was admitted with abdominal pain and was found to have a C. perfringens hepatic abscess. CASE PRESENTATION: An 84 year-old male with a history of stage IV colon adenocarcinoma, hypertension, diabetes mellitus type II, and chronic renal insufficiency presented with a complaint of abdominal pain, diarrhea, fever and chills for one day. Carcinoma of the sigmoid colon was diagnosed nine years prior with resection of the colon and subsequent resection of liver metastasis three years ago. The patient has undergone multiple cycles of chemotherapy with the last one about one month prior to his admittance. On exam the patient was afebrile with stable vitals and abdominal diffuse tenderness to palpation and mild guarding in the right upper quadrant. The rest of the physical exam was unremarkable. Initial laboratory data was significant for white blood cells 15.9 x 103/mm329, bands 25 percent, hemoglobin 7.9 g/dL. The rest of labs were at baseline for the patient. The patient was admitted and aggressively resuscitated with normal saline. He was started on Pipracillin/Tazobactam for empiric coverage. In the morning he was found to have a fever of 101.9 degrees Fahrenheit and was hypotensive. The patient was transferred to the intensive care unit with presumed sepsis. He was intubated secondary to respiratory failure and started on vasopressors. A CT of the abdomen revealed a focal bubbly air collection in right hepatic lobe suggesting abscess formation. Fluconazole, Ciprofloxacin, Vancomycin and Metronidazole were added to the antibiotic regimen. Cultures drawn the previous day came back positive for C. perfringens. STAT surgery consult was obtained, however he was deemed unstable for surgery. The patient's antibiotic regiment was switched to Clindamycin, Penicillin G, and Flucanazole. Interventional radiology drained the abscess and a pigtail catheter was placed. Cultures of the fluid revealed Clostridium perfringens and Citrobacter freundii, both of which were sensitive to Pipracillin/Tazobactam. Over the course of the following week the patient improved and was transferred out of the ICU. Cytology report from abscess fluid came back positive for metastatic adenocarcinoma of the colon and the patient opted for hospice care. DISCUSSIONS: Our patient presented with a gas gangrene liver abscess and subsequent sepsis caused by C. perfringens. The factors that contributed to the patient's recovery were diagnoses within 12 hours of admission, the abscess was drained and empiric but appropriate antibiotics were initiated within 6 hours after hospital admission. This is only the third reported case of survival of a patient with hepatic abscess and sepsis due to C. perfringens, and only the second that did not require surgery, but rather a percutaneous draining. What is unique about our patient is that compared to the prior two reported cases of survival, our patient was much more hemodynamically unstable requiring multiple pressors and respiratory support and he was deemed unstable for surgery and underwent percutaneous draining. CONCLUSION: Our case illustrates the importance of considering liver abscesses in high risk patients, as early diagnosis and treatment can ultimately lead to more favorable outcomes. More importantly our case illustrates that percutaneous drainage is a viable option in the patients that are too unstable for surgical intervention.