Case Report
Fever, night sweats, and abnormal liver enzymes Ami Schattner, Jacob Gotler Lancet 2014; 384: 376 Department of Medicine (Ami Schattner MD) and Department of Radiology (Jacob Gotler MD), Kaplan Medical Center, Rehovot, Hebrew University and Hadassah Medical School, Jerusalem, Israel Correspondence to: Prof Ami Schattner Department of Medicine, Kaplan Medical Center, POB 1, Rehovot 76100, Hebrew University and Hadassah Medical School, Jerusalem, Israel [email protected]
A
A 58-year-old man presented in February, 2014, to the emergency department with 3 weeks of fever and weight loss, and 1 week of drenching night sweats, upper abdominal pain, nausea, and vomiting. He had a history of hypertension and heavy smoking. On admission he was afebrile, with only tender hepatomegaly on examination. Blood tests showed normocytic anaemia, raised white cell count with left shift, and raised platelets, ESR, and CRP. Albumin and prothrombin time were low and he had cholestatic liver function tests: direct bilirubin 13·7 μmol/L (normal 1·7–5·1 μmol/L), alkaline phosphatase 3·43 μkat/L (normal 0·63–2·0 μkat/L), and gamma-glutamyl transpeptidase 2·2 μkat/L (normal 0·18–0·83 μkat/L). Abdominal CT showed multiple liver lesions and a mass in the sigmoid colon. The first impression was of liver metastases secondary to colorectal carcinoma. An ultrasound-guided liver biopsy on the second day in hospital yielded 50 mL of malodorous purulent fluid that grew Gram-negative bacilli, confirmed as Fusobacterium nucleatum by PCR. Blood cultures taken at the same time were negative. Reviewing the imaging we saw multiple liver abscesses with portal and hepatic vein thrombi (figure). The biliary tract and appendix were normal but sigmoid diverticulosis was present, with diverticulitis and a large adjacent abscess (figure). At laparotomy the sigmoid colon was adherent to the urinary bladder and in between was a large abscess containing pus and faecal material. The abscess was drained and a colostomy prepared. The patient was discharged after 2 weeks treatment with low molecular weight heparin and intravenous ertapenem. Ertapenem was continued for 4 more weeks through a peripherally inserted central catheter at home. At last follow-up in May, 2014, he was feeling well, with normal blood test results. Our patient had asymptomatic perforation and pelvic abscess secondary to sigmoid diverticulitis, and presented with symptoms from pylephlebitis and pyogenic liver abscesses.1 Most patients with colonic diverticulosis are B
Figure: pyogenic liver abscess (A) Coronal view of contrast-enhanced abdominal CT scan showing multiple hypodense liver lesions compatible with abscesses (green arrows) and a filling defect in a branch of the portal vein (white arrow) consistent with thrombosis (pylephlebitis). (B) axial view showing sigmoid diverticulitis with pelvic abscesses (green arrows) and free peritoneal fluid (red arrow). 376
asymptomatic,2 even those with diverticular bleeding. Diverticulitis, which occurs in 10–25% of patients with diverticulosis, is caused by transmural infection and inflammation, and can lead to perforation, peridiverticulitis, and symptoms which include fever, left lower quadrant pain, and change in bowel habit.2 Diverticulitis is rarely asymptomatic, and for it to be the source of pyogenic liver abscess is even more uncommon. In our patient, infection penetrated the sigmoid wall through the inflamed diverticula, forming a pelvic abscess and extending by venous drainage into the portal system, causing pylephlebitis: suppurative thrombophlebitis of the portal vein or one of its tributaries. Pylephlebitis, an extremely rare and often fatal complication of diverticulitis,3 can be a precursor for pyogenic liver abscess as pieces of the infected thrombus break off and seed the liver. In one series of 19 patients, 53% had pyogenic liver abscess (most with multiple abscesses), 10% had septic pulmonary emboli, and a third died. Five patients had underlying diverticulitis, most diagnosed only at autopsy.3 Biliary tract or appendix abnormalities are prominent causes of pyogenic liver abscess, but colonic lesions must be considered, including diverticulitis4 and, especially in Asia, colorectal cancer. Because pyogenic liver abscess has such variable pathology1 a microbiological diagnosis should be sought in each case. Our patient had F nucleatum anaerobic Gram-negative bacilli, which are part of the normal flora of the gastrointestinal tract, but one of the most virulent species. Early imaging by CT is crucial to the timely diagnosis of pylephlebitis and pyogenic liver abscess from complicated diverticulitis. Anticoagulation can prevent thrombus extension (which may involve the larger mesenteric veins, causing dangerous bowel ischaemia) and embolisation.3 There is no consensus, however, about anaerobic infections causing thrombotic disease.5 The combined use of broad-spectrum antibacterials (empiric until culture results become available), abscess drainage, and appropriate surgery to treat the lesion seeding the liver1,3 will improve survival. Contributors AS and JG cared for the patient. AS wrote the report. Written consent to publish was obtained. References 1 Mohsen AH, Green ST, Read RC, Mckendrick MW. Liver abscess in adults: ten years experience in a UK centre. Q JM 2002; 95: 707–802. 2 Fox JM, Stollman NH. Diverticular disease of the colon. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th edn. Philadelphia: Saunders, 2010: 2073–89. 3 Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21: 1114–20. 4 Wallack MK, Brown AS, Austrian R, Fitts WT. Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis. Ann Surg 1976; 184: 241–43. 5 Kasper DL, Sahani D, Misdraji J. Case records of the Massachusetts General Hospital. Case 25-2005. A 40-year-old man with prolonged fever and weight loss. N Engl J Med 2005; 353: 713–22. www.thelancet.com Vol 384 July 26, 2014
Fever, night sweats, and abnormal liver enzymes Ami Schattner, Jacob Gotler Lancet 2014; 384: 376 Department of Medicine (Ami Schattner MD) and Department of Radiology (Jacob Gotler MD), Kaplan Medical Center, Rehovot, Hebrew University and Hadassah Medical School, Jerusalem, Israel Correspondence to: Prof Ami Schattner Department of Medicine, Kaplan Medical Center, POB 1, Rehovot 76100, Hebrew University and Hadassah Medical School, Jerusalem, Israel [email protected]
A
A 58-year-old man presented in February, 2014, to the emergency department with 3 weeks of fever and weight loss, and 1 week of drenching night sweats, upper abdominal pain, nausea, and vomiting. He had a history of hypertension and heavy smoking. On admission he was afebrile, with only tender hepatomegaly on examination. Blood tests showed normocytic anaemia, raised white cell count with left shift, and raised platelets, ESR, and CRP. Albumin and prothrombin time were low and he had cholestatic liver function tests: direct bilirubin 13·7 μmol/L (normal 1·7–5·1 μmol/L), alkaline phosphatase 3·43 μkat/L (normal 0·63–2·0 μkat/L), and gamma-glutamyl transpeptidase 2·2 μkat/L (normal 0·18–0·83 μkat/L). Abdominal CT showed multiple liver lesions and a mass in the sigmoid colon. The first impression was of liver metastases secondary to colorectal carcinoma. An ultrasound-guided liver biopsy on the second day in hospital yielded 50 mL of malodorous purulent fluid that grew Gram-negative bacilli, confirmed as Fusobacterium nucleatum by PCR. Blood cultures taken at the same time were negative. Reviewing the imaging we saw multiple liver abscesses with portal and hepatic vein thrombi (figure). The biliary tract and appendix were normal but sigmoid diverticulosis was present, with diverticulitis and a large adjacent abscess (figure). At laparotomy the sigmoid colon was adherent to the urinary bladder and in between was a large abscess containing pus and faecal material. The abscess was drained and a colostomy prepared. The patient was discharged after 2 weeks treatment with low molecular weight heparin and intravenous ertapenem. Ertapenem was continued for 4 more weeks through a peripherally inserted central catheter at home. At last follow-up in May, 2014, he was feeling well, with normal blood test results. Our patient had asymptomatic perforation and pelvic abscess secondary to sigmoid diverticulitis, and presented with symptoms from pylephlebitis and pyogenic liver abscesses.1 Most patients with colonic diverticulosis are B
Figure: pyogenic liver abscess (A) Coronal view of contrast-enhanced abdominal CT scan showing multiple hypodense liver lesions compatible with abscesses (green arrows) and a filling defect in a branch of the portal vein (white arrow) consistent with thrombosis (pylephlebitis). (B) axial view showing sigmoid diverticulitis with pelvic abscesses (green arrows) and free peritoneal fluid (red arrow). 376
asymptomatic,2 even those with diverticular bleeding. Diverticulitis, which occurs in 10–25% of patients with diverticulosis, is caused by transmural infection and inflammation, and can lead to perforation, peridiverticulitis, and symptoms which include fever, left lower quadrant pain, and change in bowel habit.2 Diverticulitis is rarely asymptomatic, and for it to be the source of pyogenic liver abscess is even more uncommon. In our patient, infection penetrated the sigmoid wall through the inflamed diverticula, forming a pelvic abscess and extending by venous drainage into the portal system, causing pylephlebitis: suppurative thrombophlebitis of the portal vein or one of its tributaries. Pylephlebitis, an extremely rare and often fatal complication of diverticulitis,3 can be a precursor for pyogenic liver abscess as pieces of the infected thrombus break off and seed the liver. In one series of 19 patients, 53% had pyogenic liver abscess (most with multiple abscesses), 10% had septic pulmonary emboli, and a third died. Five patients had underlying diverticulitis, most diagnosed only at autopsy.3 Biliary tract or appendix abnormalities are prominent causes of pyogenic liver abscess, but colonic lesions must be considered, including diverticulitis4 and, especially in Asia, colorectal cancer. Because pyogenic liver abscess has such variable pathology1 a microbiological diagnosis should be sought in each case. Our patient had F nucleatum anaerobic Gram-negative bacilli, which are part of the normal flora of the gastrointestinal tract, but one of the most virulent species. Early imaging by CT is crucial to the timely diagnosis of pylephlebitis and pyogenic liver abscess from complicated diverticulitis. Anticoagulation can prevent thrombus extension (which may involve the larger mesenteric veins, causing dangerous bowel ischaemia) and embolisation.3 There is no consensus, however, about anaerobic infections causing thrombotic disease.5 The combined use of broad-spectrum antibacterials (empiric until culture results become available), abscess drainage, and appropriate surgery to treat the lesion seeding the liver1,3 will improve survival. Contributors AS and JG cared for the patient. AS wrote the report. Written consent to publish was obtained. References 1 Mohsen AH, Green ST, Read RC, Mckendrick MW. Liver abscess in adults: ten years experience in a UK centre. Q JM 2002; 95: 707–802. 2 Fox JM, Stollman NH. Diverticular disease of the colon. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 9th edn. Philadelphia: Saunders, 2010: 2073–89. 3 Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21: 1114–20. 4 Wallack MK, Brown AS, Austrian R, Fitts WT. Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis. Ann Surg 1976; 184: 241–43. 5 Kasper DL, Sahani D, Misdraji J. Case records of the Massachusetts General Hospital. Case 25-2005. A 40-year-old man with prolonged fever and weight loss. N Engl J Med 2005; 353: 713–22. www.thelancet.com Vol 384 July 26, 2014
