Giant Klebsiella pneumoniae pyogenic liver abscess in the left liver lobe presenting with dyspepsia and vaginal discharge

Abstract

Pyogenic liver abscess (PLA) commonly occurs in the right liver lobe, causing the typical symptoms of fever and right upper quadrant pain. Less than one-third of cases occur in the left lobe. We describe an unusual presentation of a giant left-sided PLA that was compressing the stomach and surrounding venous vasculature, causing the respective symptoms of gastro-oesophageal reflux and vaginal discharge from secondary pelvic congestion syndrome. CT revealed a solitary 14 cm×10 cm×10 cm multiloculated lesion, replacing most of the left liver lobe. It was successfully treated with intravenous antibiotics and percutaneous drainage, resulting in complete resolution at 1-year follow-up. This case explores the predisposing risk factor of diabetes in PLA and its association with Klebsiella pneumoniae, which was the offending pathogen in our patient. We also discuss the phenomenon of secondary pelvic venous congestion syndrome and compare similar cases of left-sided PLA, highlighting the different modes of presentation and treatment options.

Background

Hepatic abscess is an encapsulated suppurative collection within the liver parenchyma that can be of malignant nature, iatrogenic from biliary procedures or infectious in aetiology.¹ Main routes of infection include haematogenous spread via the hepatic artery, contiguous spread from biliary tract infections or through the portal circulation in the setting of bowel pathology (eg, diverticulitis).^2–4 Over two-thirds of pyogenic liver abscesses (PLA) occur in the right liver lobe as it receives blood mainly from the superior mesenteric vein, causing the typical symptoms of right upper quadrant pain and tender hepatomegaly.⁵ On the other hand, the left lobe is less likely to be affected as it receives blood mainly from the splenic vein, resulting in a more enigmatic presentation.^{6 7} Atypical symptoms can further arise in cases of a giant abscess (characteristically >10 cm) as it exerts anatomical compression onto surrounding structures and can rarely rupture into adjacent thoracic, pericardial and peritoneal cavities.^8–10 Unusual presentations can also be driven by underlying risk factors such as diabetes mellitus, which is associated with a higher incidence of the increasingly dominant pathogen, Klebsiella pneumoniae.^11–13 Surgical drainage is usually recommended for abscesses >5 cm.¹⁴ Here, we describe a woman with type 2 diabetes mellitus (T2DM) who developed a giant K. pneumoniae PLA, replacing the entire left liver lobe and causing a constellation of atypical symptoms and a potentially high-risk complication of pericardial effusion, all of which completely resolved after a combination of intravenous antibiotics and percutaneous drainage.

Case presentation

A female patient presented with 2 weeks of epigastric and retrosternal burning discomfort, associated with early satiety after meals. Symptoms initially improved with omeprazole and antacids but worsened in the last 2 days, during which she noticed a tender firmness over the left hypochondrium. This was followed by a single episode of fever at 38.4°C and eruption of herpes labialis, which was treated with over-the-counter cold sore ointment. Multiple lateral flow tests for COVID-19 were negative. Given the worsening symptoms, she presented to the emergency department for further investigation and was transferred to the surgical assessment unit for suspected cholecystitis. While awaiting surgical review, she experienced an episode of brown vaginal discharge. There was no pelvic pain, history of post-menopausal bleeding, unintentional weight loss, diarrhoea or vomiting. Apart from T2DM which was fairly well-controlled as reflected by a recent glycated haemoglobin (HbA1c) of 50 mmol/mol (6.7%), she had been fit and well with no prior hospital attendances, and only took atorvastatin and metformin. She was a non-smoker, non-alcoholic and had not travelled abroad in the last 2 years since visiting America.

On examination, she appeared comfortable but febrile at 38.3°C, tachycardic 113 bpm with normal blood pressure 118/80, oxygen saturation and weight 54 kg. Peripheral examination revealed multiple herpes labialis but no peripheral stigmata of chronic liver disease. Moderate tenderness was elicited over the left hypochondrium and epigastrium without guarding. Auscultation revealed normal bowel and heart sounds but reduced air entry in the left lung base.

Investigations

Laboratory tests showed a raised white cell count 20.27×10⁹/L, neutrophilia 18.26×10⁹/L, C-reactive protein 241 mg/L, alkaline phosphatase 350 IU/L, alanine transaminase 146 IU/L, normal bilirubin 23 µmol/L, amylase 42 IU/L and serum creatinine 52 µmol/L. Platelets increased to 1085×10⁹/L, which the haematologists attributed to reactive thrombocytosis. Chest radiograph showed a small left pleural effusion. A contrast CT of abdomen and pelvis was requested, querying cholecystitis or pancreatitis. Instead, it revealed a giant 14 cm × 10 cm × 10 cm multiloculated gas-containing pyogenic abscess, replacing the left liver lobe and compressing the greater curvature and fundus of the stomach (figure 1A). A small reactive left pleural effusion and pericardial effusion were noted (figure 1B). No abnormality was found in the gallbladder, biliary tract, pancreas, small and large bowels. Unexpectedly, the endometrium appeared abnormally widened in a retroverted uterus with a prominent left ovary and surrounding uterine and ovarian venous varices (figure 2A). No venous thromboses were detected in the inferior vena cava, portal, renal and ovarian veins. Subsequent transvaginal ultrasound reported a post-menopausal uterus of normal in shape with tortuous left varicose veins measuring up to 6 mm in diameter and slow retrograde flow on Doppler, confirming pelvic venous congestion (figure 2B).

Figure 1.

(A) Sagittal and coronal CT of giant liver abscess measuring up to 14 cm diameter, compressing the stomach and surrounding venous vasculature; (B) sagittal CT view of small pericardial effusion and small left pleural effusion (left) and 10 Fr catheter inserted under fluoroscopic guidance to treat the left hepatic abscess (right); (C) CT after 1 year showing resolution of the abscess.

Figure 2.

(A) Sagittal and coronal CT showing surrounding uterine and left ovarian venous varices; (B) transvaginal ultrasound showing tortuous varicose veins measuring up to 6 mm in diameter with corresponding colour flow Doppler, confirming pelvic venous congestion syndrome.

Differential diagnosis

It was important to exclude other types of hepatic abscess. First, malignant liver abscesses with necrotic cores can also develop bacterial infections, causing gas-containing lesions that appear solitary in primary hepatocellular carcinoma or multiple in metastases.⁷ Liver metastases can occur with ovarian cancer, which was a concern in this patient who had a prominent left ovary and post-menopausal vaginal discharge. However, the relatively short history of symptoms without unintentional weight loss, thin-walled appearance of the PLA and absence of multiple liver lesions made malignancy unlikely. Second, amoebic liver abscess was excluded after two negative serology tests for Entamoeba histolytica during the acute and convalescence stage. Finally, the presence of cold sores raised suspicion of herpes simplex virus as a rare cause of PLA; however, this was only reported in severely immunocompromised states, for example, on chemotherapy,¹⁵ and the hepatitis serology panel was negative, making this differential very unlikely.

Even though an infectious aetiology was apparent, the primary aetiology was unclear. There was no clinical or radiological evidence of biliary tract infection (eg, cholangitis, cholecystitis), portal tract infections (eg, diverticulitis, pancreatitis, appendicitis) or haematogenous spread after two negative blood cultures. Cryptogenic invasive K. pneumoniae PLA has been reported in patients with T2DM, and gastrointestinal carriage of this bacteria have been found in this population.^{16 17} On balance, this was probably bacterial gut translocation into the portal circulation and was made more likely by a temporarily reduced immunity in the setting of T2DM and a concurrent viral illness, as evidenced by the eruption of herpes labialis.

Treatment

She was empirically started on intravenous piperacillin-tazobactam antibiotic. Given the presence of high-risk features, an urgent multidisciplinary discussion was held between the hepatobiliary surgeons and interventional radiologists to decide on the best approach. Several concerns were raised. First, the PLA diameter >10 cm and small rim of liver parenchyma increased the risk of rupture into the peritoneum, hence antibiotic therapy alone would not suffice. Second, the patient has a small pericardial effusion which could develop into life-threatening tamponade if there was further delay in PLA drainage.¹⁸ Third, its location in the left liver lobe within a highly vascular parenchyma and presence of T2DM made surgical drainage unfavourable as it posed a greater risk of major bleeding, contiguous spread to other segments and septic shower. Consequently, the following morning, she underwent an uncomplicated percutaneous catheter drainage via a left transhepatic approach (figure 1B). A 10 Fr locking drain was inserted and 50 mL of pus was aspirated for microbiology assessment before connecting to a Redovac high-vacuum bottle. As the drainage fluid cultured fully-sensitive K. pneumoniae, she was stepped down to co-amoxiclav, given intravenously for 48 hours followed by a 2-week oral course. After 15 days of drainage, the catheter was removed as the output was <20 mL a day and repeat contrast CT abdomen confirmed a reduction in the PLA to 4.1 cm × 4.3 cm × 2.1 cm.

Outcome and follow-up

One month after drain removal, an ultrasound liver was performed, showing no evidence of the previous liver abscess. She was also seen by a gynaecologist and underwent an endometrial pipelle biopsy which showed no evidence of dysplastic cells. In the following year, no further gynaecological symptoms were reported and a repeat contrast CT abdomen and pelvis showed resolution of the previous liver abscess with only subtle residual hypodensities in segment II and normal ovaries without venous varicosities (figure 1C). Over the last year, she has returned to a fit and active lifestyle without any symptoms. HbA1c has also reduced to 43 mmol/mol (6.1%).

Discussion

We will discuss the unusual clinical presentation of this giant PLA by comparing with other cases of left-sided hepatic abscesses, explore the significance of K. pneumoniae and T2DM as risk factors and finally, discuss the evidence-based management of giant multiloculated PLAs.

After a literature search on MEDLINE and EMBASE using keywords related to case report or series on left liver/hepatic abscesses, only one case described compression of the gastric antrum by a similarly large PLA (14×12 cm) caused by Candida albicans,¹⁹ but no symptoms of dyspepsia were reported. Based on other cases of left-sided PLA summarised in table 1, the most common symptoms included fever, malaise and abdominal pain. In contrast, our patient initially reported symptoms of heartburn due to extrinsic compression of the stomach before developing fever. Due to the close proximity between the stomach and liver, ingestion of fish or chicken bones has also been reported as a cause of PLA^20–22; however, no evidence of foreign bodies were found on CT imaging in our patient. Given the enormity of the abscess, symptoms related to anatomical compression should always be considered in giant lesions, for example, one case of a large hepatic cyst caused acute breathlessness and chest discomfort due to compression on the right ventricle.²³ If our patient had not received early definitive treatment, the small pericardial effusion may have worsened to tamponade, which occurred in a 30-year-old man who was diagnosed with a PLA after 6 weeks of symptoms, requiring emergency pericardiocentesis.²⁴

Table 1.

Comparison with other cases of hepatic abscesses in the left liver lobe

Author	Age and gender	Presentation	Abscess size (cm)	Microbiology	Treatment
Our case	60 F	Dyspepsia, vaginal discharge, Left upper quadrant pain	14×10×10	Klebsiella pneumoniae	Antibiotics+PD
Spindel et al24	30 M	Malaise, fever, pericardial effusion	Not reported	Roseomonas mucosa	Antibiotics+pericardiocentesis+
Maricuto et al40	54 M	Diarrhoea and dysentery	Only craniocaudal reported-18 cm	Entamoeba histolytica	Antibiotics+PD+exploratory laparotomy
Molinario et al19	82 F	Fever of unknown origin	14×12 compressing gastric antrum	Candida albicans	EUS-guided drainage+LAMS
Hernández-Villafranca et al20	73 F	Epigastric pain and fever after ingestion of fish bone	Not reported	Unknown	Antibiotics+laparoscopic surgery
Bekki et al41	51 M	Fever, anorexia- fish bone perforated gastric wall	4×5	Streptococcus anginosus	Laparoscopic surgery
Li et al21	58 M	Fever eating ingesting fish bone	Not reported	Unknown	Left hepatic lobe resected laparoscopically
Jayasimhan et al42	51 F	Generalised abdominal pain	9.0×9.2×9.3	Fusobacterium nucleatum	Antibiotics+PD
Romano et al43	58 M	Weight loss, premature satiety, abdominal pain, fever	5×11×15	Unknown	Antibiotics+laparoscopic drainage
Santos et al22	62 F	Epigastric pain and fever after ingesting chicken bone	8.5×7.0	Microbiology negative	Laparotomy to retrieve chicken bone

EUS, endoscopic ultrasound; F, female; LAMS, lumen-apposing metal stent; M, male; PD, percutaneous drainage.

To the best of our knowledge, no other cases of PLA-induced pelvic venous congestion syndrome (PCS) have been described. There was one report of a giant peritoneal hydatid cyst provoking pelvic venous congestion and causing pelvic pain by obstructing the pelvic venous drainage.²⁵ With the left ovarian vein having a longer course than its right counterpart before draining into the renal vein and its absence of valves, left ovarian varicosities can occur in the context of left-sided colonic, renal or hepatic masses.²⁶ PCS is classified into primary ovarian reflux (commonly found in younger pre-menopausal women) or secondary obstructive impedance to venous return (commonly in post-menopausal women such as in our case). On ultrasound, it is characterised by tortuous pelvic veins of >4 mm diameter with slow Doppler flow <3 cm/s (figure 2B).²⁷ PCS has a heterogeneous clinical presentation, ranging from pelvic pain (absent in our patient), dyspareunia, menstrual bleed or vaginal discharge.²⁸ Secondary PCS is treated by addressing the underlying cause of the mechanical obstruction.

PLA can be differentiated into gas-forming and non-gas forming lesions. In a study of 393 patients with PLA, gas-forming abscesses were more likely to be associated with K. pneumoniae, of biliary source and often related to hepatobiliary surgery.²⁹ Our patient had a gas-containing PLA infected by the same pathogen but the cause was cryptogenic. Chen et al found that the odds of finding cryptogenic PLA was 8.4 times more likely in T2DM (OR 8.4, 95% CI 2.1 to 33.4, p=0.003), more often due to K. pneumoniae (OR 5.0, 95% CI 1.1 to 22.7, p=0.035) and less likely to cause upper abdominal pain (52% vs 70%, p=0.02) than non-cryptogenic PLA.³⁰ An animal model suggested that K. pneumoniae can cross the intestinal barrier to cause PLA, providing a possible explanation for cryptogenic cases.³¹ One study sampled the gases within K. pneumoniae PLA and found predominantly nitrogen gas produced by bacterial fermentation of glucose.³² It is thought that gas accumulation is promoted by the hyperglycaemic environment for microbial growth, rapid catabolism and diabetic microangiopathy that impedes the elimination of gaseous by-products within the liver lesion.³² Poor glycaemic control (HbA1c >53–86 mmol/mol, ie, 7–10%) was found to be associated with a higher rate of septic metastases (eg, meningitis, pneumonia, endophthalmitis) and a higher 6-month mortality.^{17 33} Hence, controlling diabetes and acute hyperglycaemia are crucial in cases of PLA. Our patient’s HbA1c was reasonably low at 50 mmol/mol, conferring the good prognosis seen after treatment.

The choice of treatment strategy for giant multiloculated abscesses remains controversial. Previous studies have suggested that percutaneous drainage (PD) of giant (>10 cm) PLA resulted in higher failure and complication rates, especially for multiloculated lesions, advocating for surgical drainage.^{14 34} However, with recent advances in percutaneous techniques, there has been a recent trend towards the less invasive PD approach, which has proved to be safe and effective even in giant multiloculated abscesses. Liu et al found that PD was successful in 109 patients (54 had multiloculated PLA) regardless of size and complexity.³⁵ In another study comparing PD with surgical drainage, PD was associated with a lower risk of bile leakage, abdominal bleeding and shorter hospital stays (median 12 vs 29 days, p=0.025).³³ Surgery may thus be reserved for cases where PD had failed (eg, inadequate clinical response or inaccessible due to anatomical location), incomplete drainage or abscess rupture.

Nonetheless, the less invasive laparoscopic drainage approach would also have served as a safe and feasible alternative for our patient, but this depended on local expertise. A meta-analysis of 190 studies adopting laparoscopic drainage in 49% of PLA found a low rate of biliary leakage, postoperative residual abscess (4.22% cases) and no mortality.³⁶ Following this, Pickens et al proposed a multimodal algorithm based on the type of abscess, whereby antibiotics alone were used for PLAs <3 cm, PD for unilocular ≥3 cm lesions and laparoscopic drainage for ≥3 cm multiloculated abscesses, which was associated with a lower failure rate than PD (4% vs 28%, p=0.018).³⁷ Another modern approach is endoscopic ultrasound-guided transgastric drainage which deploys an electrocautery-enhanced lumen-apposing metal stent into the fluid collection through the stomach.³⁸ This could have been a potential alternative for our patient, given the close proximity of the PLA to the stomach. Successful cases of left PLA drained using this method have been described.^{19 39} The stent is removed once the abscess resolves. This technique would mitigate the risks of tube migration and accidental tube removal associated with PD.

In conclusion, this case has highlighted that giant left-sided PLA can present atypically with symptoms related to anatomical compression, including the first report of secondary pelvic congestion syndrome. T2DM and K. pneumoniae are important risk factors for the development of gas-containing, multiloculated and cryptogenic PLA. Irrespective of the size and loculation of the abscess, PD can be considered safe and feasible in all accessible PLAs; however laparoscopic surgical drainage should also be considered in selected cases.

Patient’s perspective.

I had never experienced heartburn before until the 2 weeks before I ended up in hospital. The omeprazole and anti-acid tablets were no longer working and the stomach pain worsened. After I developed multiple cold sores and fever, I was concerned it was COVID-19 so I attended A&E. The dark brown vaginal discharge frightened me as I had never experienced any problems like this before or after menopause. I am still surprised that this was due to a large liver abscess but glad that we managed to treat it. After a year since treatment, I feel very well and my diabetes has also been much better than before.

Learning points.

• The presence of ovarian varicosities, vaginal discharge with or without pelvic pain in the setting of a giant left-sided hepatic abscess can indicate secondary pelvic venous congestion syndrome, which can be reversed by drainage of the abscess.

• Cryptogenic abscesses are more likely to occur in patients with diabetes and Klebsiella pneumoniae, which has been found to easily cross the intestinal barrier to seed into the liver.

• Percutaneous drainage can be a safe and effective approach even for giant multiloculated liver abscesses while surgical drainage (preferably laparoscopic) should be reserved in cases of failed clinical response, abscess rupture, high risk of recurrence or inaccessible abscesses.

• Optimal diabetic control in patients with pyogenic liver abscesses is associated with a better prognosis.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).