SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Hepatopulmonary fistulas are quite rare, a complication which can be due to primary etiologies such as hydatid or pyogenic cysts (1). These insults cause transdiaphragmatic infiltration leading to rupture at the lower lung leading to the formation of a fistula. Secondary causes are congenital abnormalities, surgical or penetrating trauma. Our patient developed an extremely rare complication of fistulization with the right lung pleura due to a suppurative hepatic collection leading to a complicated clinical presentation. There are known septic embolic or constitutional symptoms associated with the diagnosis which were not present in our case, rather acute hypoxic respiratory failure and septic shock due to rupture of the hepatic abscess.
CASE PRESENTATION: A 59-year-old female with a recent history of a benign liver tumor presented for shortness of breath and dry cough for two days. On physical exam, she was tachypneic and increased work of breathing. Vital signs were significant for oxygen desaturation to 86% on room air, required mechanical ventilation. She was admitted to the intensive care unit for acute respiratory failure due to possible multifocal pneumonia and rule out COVID-19 Upon admission evaluation, laboratory results significant for transaminitis (Alk Phos 353, AST 197 and ALT 60) Chest X-ray (Figure 1) raised right hemidiaphragm, right lower lobe atelectasis and bilateral alveolar infiltrates. CT AP with IV contrast revealed a large right sub diaphragmatic abscess with a right-sided empyema (Figure 2) Upon review of daily CXR, day 6 of the admission, new loculated pneumothoraces in the upper and middle right lung. Chest tube was placed for the pnuemothoraces. The pleural fluid was exudative and neutrophil predominant. Followed by an IR drainage of the liver abscess yielding 60 cc of brown purulent fluid. The spontaneous pneumothorax was likely in the setting of a cystopleural fistula resulting from ruptured hepatic abscess given similar microbiology with anaerobic gram positive rod growth from the IR guided liver abscess drainage and the chest tube drainage.
DISCUSSION: Hepatopulmonary fistulas may have benign courses but there is a significant mortality rate due to septic shock and florid infection. A pyogenic abscess causes obstruction of the biliary tree allowing for bacterial overgrowth complicated by rupture leading to peritonitis or sepsis.
CONCLUSIONS: Our case is a rare presentation showing the severe progression of a pyogenic liver abscess allowing for this communication between the lung and liver. This case emphasizes the importance of early recognition of infectious liver abscesses and early intervention.
Reference #1: Gulamhussein, Patrini, Pararajasingham, Adams, Shukla, Velissaris, Lawrence, Panagiotopoulous “Hepatopulmonary Fistula: a life threatening complication of hydatid cyst” J Cardiothorac Surg 2015
Reference #2: Abbas M, Khan F, Muhsin S, Al-Dehwe “Epidemiology, Clinical features and outcome of Liver Abcsess: A single Reference Center Experience in Qatar” Oman Med J 2014
DISCLOSURES: No relevant relationships by Kinjal Patel, source=Web Response
No relevant relationships by Jean Singh, source=Web Response
No relevant relationships by Ivan Wong, source=Web Response