Endocrine DOI 10.1007/s12020-014-0227-9
LETTER TO THE EDITOR
Tumor-like pyogenic liver abscess caused by Klebsiella pneumoniae in diabetes Saranya Buppajarntham • Mahek Shah Parichart Junpaparp
•
Received: 23 October 2013 / Accepted: 22 February 2014 Ó Springer Science+Business Media New York 2014
We have read a very interesting case reported by Williams et al. [1] ‘‘Occult pyogenic liver abscess in an adolescent with type 2 diabetes’’ which described a case of Klebsiella liver abscess (KLA) in a poorly controlled diabetic with an initial presentation of fever of unknown origin. In this letter, we would like to highlight another atypical presentation of KLA in a diabetic patient that presented as a tumor-like liver mass. A 63-year-old Vietnamese male with diabetes had a kidney biopsy 1 month prior to admission for evaluation of nephrotic syndrome that was complicated by the development of a kidney hematoma. Computed tomography (CT) of abdomen was performed to reassess the kidney hematoma when an ill-defined multicystic liver mass was incidentally discovered (Fig. 1, panel a–c). The patient had stable vital signs and was afebrile without any evidence of abdominal pain or leukocytosis. Since his blood cultures remained negative, a necrotizing tumor mass was the most likely diagnosis at that point. Additionally, the pathologic report of the kidney biopsy showed nodular diabetic glomerulosclerosis. The patient was discharged home to be followed up with tumor marker tests and further evaluation as an outpatient. A month after discharge, the patient returned with significant fatigue and anemia (hemoglobin drop from 7 to 5 g/dl) accompanied by mild right-sided upper abdominal pain. On exam, his vital signs were stable, he was afebrile, and well-oriented but looked pale and chronically ill. An abdominal exam revealed hepatomegaly with mild tenderness localized in the right upper quadrant. Tumor S. Buppajarntham (&) M. Shah P. Junpaparp Internal Medicine Department, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA e-mail: [email protected]
marker levels from the previous admission were within normal range (alpha fetoprotein level: 1.4 ng/ml and CA19-9: 32 U/ml). Laboratory results were as follows: white blood cell count 10 9 103/mm3 (N 80 %, L 9 %), alkaline phosphatase 169 IU/l, total bilirubin 0.2 mg/dl, direct bilirubin 0.2 mg/dl, albumin 1.4 g/dl, globulin 4.7 g/dl, aspartate transaminase 27 IU/l, alanine transaminase 16 IU/l, international normalized ratio 1.1, blood glucose 130 mg/dl, and serum creatinine 2.6 mg/dl. Due to chronic kidney disease, a CT scan of the abdomen was performed without use of intravenous contrast that demonstrated an increase in the size of the liver mass (Fig. 1 panel d–f). The liver mass was growing gradually for over a month without any signs and symptoms of infection, which was again attributed to likely being a necrotizing tumor mass. There was a serious concern for chronic bleeding from the site of the tumor and the patient received a right-sided hepatic lobectomy for bleeding control and tissue diagnosis. Surprisingly, the pathology report revealed a liver abscess with chronic inflammation and the tissue cultures grew pansensitive Klebsiella pneumoniae. KLA is an emerging disease in North America, frequently found in the Asian population, diabetics, and patients with chronic kidney disease [2]. K. pneumonia was isolated in 7–27 % of pyogenic liver abscess in USA but only a few cases of metastatic infection have been reported such as endophthalmitis, lung abscess, and meningitis. The incidence is higher in Taiwan, Japan, and south-east Asia. Common presentations are fever, abdominal pain, and leukocytosis which were initially absent in our case and misled us to pursue for liver malignancy. The findings suggestive of KLA on CT or ultrasonography are the formation of gas within the abscesses, pneumatosis in the biliary tree, an irregular abscess border, and an overall solid appearance with internal necrotic debris. Since several hepatic neoplasms or metastatic liver diseases
123
Endocrine
Fig. 1 Computed tomography (CT) of abdomen without contrast from 1 month prior showed a large ill-defined soft tissue liver mass on right lobe, no intra-hepatic or extra-hepatic biliary ductal dilatation
(panel a–c); and CT of abdomen from present admission compared to previous study revealed a large multicystic mass which has significantly increased in size and extended to the capsule (panel d–f)
would have similar appearances on CT scan to liver abscesses, dynamic liver magnetic resonance imaging (MRI) with contrast or CT imaging with contrast is required in cases with unclear clinical manifestations. Keeping in mind the abnormal baseline kidney function in our patient, these tests were contraindicated. Choi et al. [3] postulated that MRI using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid differentiated an abscess from neoplasms by non-defect of the arterial enhancing rim on hepatobiliary phase (the defect zone in arterial enhancing rim is favored neoplastic diseases). We conclude that a multicystic liver mass in diabetic Asian populations may represent a KLA even in the absence of signs and symptoms of infection. Further imaging as liver-enhancing MRI might have a role in the patients with unclear symptoms.
Disclosure
123
All authors has no conflict of interest.
References 1. R. Williams, N.S. Larson, J.E. Pinsker, Occult pyogenic liver abscess in an adolescent with type 2 diabetes. Endocrine 45(2), 335–336 (2014). doi:10.1007/s12020-013-0036-6 2. J.Y. Hui, M.K. Yang, D.H. Cho, A. Li, T.K. Loke, J.C. Chan et al., Pyogenic liver abscesses caused by Klebsiella pneumoniae: US appearance and aspiration findings. Radiology 242(3), 769–776 (2007) 3. S.H. Choi, C. Hee Lee, B.H. Kim, J. Lee, J.W. Choi, Y.S. Park et al., Nondefect of arterial enhancing rim on hepatobiliary phase in 3.0-T gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced liver magnetic resonance imaging: distinguishing hepatic abscess from metastasis. J. Comput. Assist. Tomogr. 37(6), 849–855 (2013)
LETTER TO THE EDITOR
Tumor-like pyogenic liver abscess caused by Klebsiella pneumoniae in diabetes Saranya Buppajarntham • Mahek Shah Parichart Junpaparp
•
Received: 23 October 2013 / Accepted: 22 February 2014 Ó Springer Science+Business Media New York 2014
We have read a very interesting case reported by Williams et al. [1] ‘‘Occult pyogenic liver abscess in an adolescent with type 2 diabetes’’ which described a case of Klebsiella liver abscess (KLA) in a poorly controlled diabetic with an initial presentation of fever of unknown origin. In this letter, we would like to highlight another atypical presentation of KLA in a diabetic patient that presented as a tumor-like liver mass. A 63-year-old Vietnamese male with diabetes had a kidney biopsy 1 month prior to admission for evaluation of nephrotic syndrome that was complicated by the development of a kidney hematoma. Computed tomography (CT) of abdomen was performed to reassess the kidney hematoma when an ill-defined multicystic liver mass was incidentally discovered (Fig. 1, panel a–c). The patient had stable vital signs and was afebrile without any evidence of abdominal pain or leukocytosis. Since his blood cultures remained negative, a necrotizing tumor mass was the most likely diagnosis at that point. Additionally, the pathologic report of the kidney biopsy showed nodular diabetic glomerulosclerosis. The patient was discharged home to be followed up with tumor marker tests and further evaluation as an outpatient. A month after discharge, the patient returned with significant fatigue and anemia (hemoglobin drop from 7 to 5 g/dl) accompanied by mild right-sided upper abdominal pain. On exam, his vital signs were stable, he was afebrile, and well-oriented but looked pale and chronically ill. An abdominal exam revealed hepatomegaly with mild tenderness localized in the right upper quadrant. Tumor S. Buppajarntham (&) M. Shah P. Junpaparp Internal Medicine Department, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141, USA e-mail: [email protected]
marker levels from the previous admission were within normal range (alpha fetoprotein level: 1.4 ng/ml and CA19-9: 32 U/ml). Laboratory results were as follows: white blood cell count 10 9 103/mm3 (N 80 %, L 9 %), alkaline phosphatase 169 IU/l, total bilirubin 0.2 mg/dl, direct bilirubin 0.2 mg/dl, albumin 1.4 g/dl, globulin 4.7 g/dl, aspartate transaminase 27 IU/l, alanine transaminase 16 IU/l, international normalized ratio 1.1, blood glucose 130 mg/dl, and serum creatinine 2.6 mg/dl. Due to chronic kidney disease, a CT scan of the abdomen was performed without use of intravenous contrast that demonstrated an increase in the size of the liver mass (Fig. 1 panel d–f). The liver mass was growing gradually for over a month without any signs and symptoms of infection, which was again attributed to likely being a necrotizing tumor mass. There was a serious concern for chronic bleeding from the site of the tumor and the patient received a right-sided hepatic lobectomy for bleeding control and tissue diagnosis. Surprisingly, the pathology report revealed a liver abscess with chronic inflammation and the tissue cultures grew pansensitive Klebsiella pneumoniae. KLA is an emerging disease in North America, frequently found in the Asian population, diabetics, and patients with chronic kidney disease [2]. K. pneumonia was isolated in 7–27 % of pyogenic liver abscess in USA but only a few cases of metastatic infection have been reported such as endophthalmitis, lung abscess, and meningitis. The incidence is higher in Taiwan, Japan, and south-east Asia. Common presentations are fever, abdominal pain, and leukocytosis which were initially absent in our case and misled us to pursue for liver malignancy. The findings suggestive of KLA on CT or ultrasonography are the formation of gas within the abscesses, pneumatosis in the biliary tree, an irregular abscess border, and an overall solid appearance with internal necrotic debris. Since several hepatic neoplasms or metastatic liver diseases
123
Endocrine
Fig. 1 Computed tomography (CT) of abdomen without contrast from 1 month prior showed a large ill-defined soft tissue liver mass on right lobe, no intra-hepatic or extra-hepatic biliary ductal dilatation
(panel a–c); and CT of abdomen from present admission compared to previous study revealed a large multicystic mass which has significantly increased in size and extended to the capsule (panel d–f)
would have similar appearances on CT scan to liver abscesses, dynamic liver magnetic resonance imaging (MRI) with contrast or CT imaging with contrast is required in cases with unclear clinical manifestations. Keeping in mind the abnormal baseline kidney function in our patient, these tests were contraindicated. Choi et al. [3] postulated that MRI using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid differentiated an abscess from neoplasms by non-defect of the arterial enhancing rim on hepatobiliary phase (the defect zone in arterial enhancing rim is favored neoplastic diseases). We conclude that a multicystic liver mass in diabetic Asian populations may represent a KLA even in the absence of signs and symptoms of infection. Further imaging as liver-enhancing MRI might have a role in the patients with unclear symptoms.
Disclosure
123
All authors has no conflict of interest.
References 1. R. Williams, N.S. Larson, J.E. Pinsker, Occult pyogenic liver abscess in an adolescent with type 2 diabetes. Endocrine 45(2), 335–336 (2014). doi:10.1007/s12020-013-0036-6 2. J.Y. Hui, M.K. Yang, D.H. Cho, A. Li, T.K. Loke, J.C. Chan et al., Pyogenic liver abscesses caused by Klebsiella pneumoniae: US appearance and aspiration findings. Radiology 242(3), 769–776 (2007) 3. S.H. Choi, C. Hee Lee, B.H. Kim, J. Lee, J.W. Choi, Y.S. Park et al., Nondefect of arterial enhancing rim on hepatobiliary phase in 3.0-T gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced liver magnetic resonance imaging: distinguishing hepatic abscess from metastasis. J. Comput. Assist. Tomogr. 37(6), 849–855 (2013)
