S2818 When the Good Goes Bad: Pyogenic Liver Abscess Due to Lactobacillus

Introduction: Lactobacillus is a rod-shaped bacteria normally found in the human gastrointestinal and genitourinary tract. It is a gram positive, non-spore forming bacteria that acts to prevent bacterial proliferation by producing lactic acid. Because of this, Lactobacilli are generally considered “good bacteria”. However, with certain comorbidities and risk factors it has the potential to migrate out of their normal environment and cause complications. In a few cases, Lactobacilli-causing hepatic abscesses have been reported, and in those cases, concurrent use of Lactobacilli containing probiotics was seen. This case demonstrates a pyogenic hepatic abscess growing Lactobacilli in the setting of recently diagnosed, uncontrolled diabetes. Case Description/Methods: A 34-year-old Hispanic female with a pertinent medical history of a cholecystectomy and recently diagnosed Type 2 diabetes presented with a one-month history of right sided flank pain with fevers. Vital signs were stable on arrival. Lab work did not show leukocytosis and was only significant for a HgA1c of 11.4. Initial imaging revealed a 9.3 cm multiloculated hypoattenuating lesion extending into the chest wall. The patient was started on antibiotics and underwent percutaneous drainage of the hepatic abscess with improvement in her symptoms. The abscess cultures grew Lactobacillus rhamnosus. Based on repeat imaging, additional drains were placed. The patient’s hospital course was complicated by a pleural effusion requiring drainage and ICU-level monitoring; however, she remained stable and was discharged after transition to oral antibiotics. The patient had close outpatient follow up and her drains were then removed. Discussion: Pyogenic hepatic abscesses are a rare occurrence, especially those caused by Lactobacillus. In previously reported cases, the main inciting factors were probiotic use, previous ERCPs and post-cholecystectomies. What makes this case interesting is the lack of any obvious causes. The patient had a history of a cholecystectomy, but it was years prior. The main risk factor our patient had was uncontrolled diabetes. In the literature, there have been very few cases that describe diabetes as the cause of a Lactobacilli liver abscess. The importance of diagnosis and treatment is to prevent Lactobacillus seeding causing bacteremia, as Lactobacillus bacteremia carries a 30% mortality. As diabetes is a prevalent condition it is vital for physicians to be aware of rare complications, such as pyogenic hepatic abscesses.Figure 1.: Abdominal MRI showing a multiloculated cystic focus extending from hepatic segment VII to hepatic segment VI with abdominal wall involvement Figure 2. Abdominal CT scan after drain placement showing decrease in volume of the multiloculated hepatic collection.