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Hepatic Actinomycotic Abscess With Pleural Effusion as a Complication of Cholecystectomy FREE TO VIEW

Sandeep Sahay, MD; Brandy McKelvy, MD
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University of Texas, Health Science Center at Houston, Houston, TX

Chest. 2013;144(4_MeetingAbstracts):183A. doi:10.1378/chest.1705343
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SESSION TITLE: Infectious Disease Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Actinomycosis is a rare bacterial infection characterized by indolent suppuration that crosses tissue planes and leads to the formation of draining sinuses. It is rarely reported as a complication of cholecystectomy.

CASE PRESENTATION: A 43-year old man admitted to ICU with acute on chronic abdominal pain. Patient has been experiencing off and on abdominal pain for the last one-year. 15 months ago patient underwent a laparoscopic cholecystectomy that was complicated by biloma formation that was repaired after a repeat surgery. However, abdominal pain persisted with significant nausea, vomiting and weight loss. Three months prior to admission, patient was found to have liver abscess that was drained percutaneously. Since then, liver abscesses were drained repeatedly along with the multiple courses of the antibiotics. His co-morbities included diabetes mellitus, hypertension and coronary artery disease. On examination, breath sounds were absent on the right lower chest with tenderness to palpation in the right upper abdominal quadrant. His WBC count was 12,000 cells per microliter. Alanine aminotransferase and aspartate aminotransferase were normal. Alkaline phosphatase was elevated to 723 units per liter. Computed tomography of the chest and abdomen revealed 6.8 cm large liver abscess in the right lobe of the liver along with the large right-sided loculated pleural effusion (Figure 1). Pleural fluid was exudative and was drained. Due to the persistent nature of the liver abscess, right hemi-hepatectomy was performed. Histo-pathology of the resected liver showed tissue invasion by actinomycetes confirming the diagnosis (Figure 2). Decortication was performed for the right loculated pleural effusion. Patient was started on Penicillin treatment.

DISCUSSION: Actinomycetes are the normal flora of the oral cavity and the lower gastrointestinal tract. Gastrointestinal infection frequently follows loss of mucosal integrity such as with surgery, intra-abdominal inflammation, or trauma. The diagnosis of actinomycosis typically requires anaerobic cultures. Post-cholecystectomy actinomycosis has been reported only twice in the medical literature. On both the occasions, it was secondary to dropped gallstones during cholecystectomy. The abscesses described were retroperitoneal and peri-hepatic. Our case is unique as it is the first report of actinomycotic liver abscess with concominant pleural effusion managed with hepatectomy, as a complication of laparoscopic cholecystectomy.

CONCLUSIONS: Actinomycosis should be considered in the patients with recurrent hepatic abscesses who have had previous laparoscopy cholecystectomy. Anaerobic culturing may facilitate in diagnosis.

Reference #1: Vyas JM et al. Abdominal Abscesses Due to Actinomycosis after Laparoscopic Cholecystectomy: Case Reports and ReviewClinical Infectious Diseases 2007; 44:e1-4

Reference #2: Ramia JM et al. Retroperitoneal actinomycosis due to dropped gallstones. Surg Endosc 2004; 18: 345-349

DISCLOSURE: The following authors have nothing to disclose: Sandeep Sahay, Brandy McKelvy

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