Reported is an unusual case of pyogenic liver abscess and septic thrombophlebitis of the portal vein in a 44-year-old male caused by Propionibacterium acnes successfully managed with a combination of percutaneous drainage and antimicrobial therapy. To the best of our knowledge, this is the first report of this bacterium isolated in pure culture as the sole etiologic organism of pyogenic liver abscess and pylephlebitis in an adult patient

Arash Poursina

Sharon Weissman

Case Reports in Hepatology

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Propionibacterium acnes Pyogenic Liver Abscess and Pylephlebitis

Reported is an unusual case of pyogenic liver abscess and septic thrombophlebitis of the portal vein in a 44-year-old male caused byPropionibacterium acnessuccessfully managed with a combination of percutaneous drainage and antimicrobial therapy. To the best of our knowledge, this is the first report of this bacterium isolated in pure culture as the sole etiologic organism of pyogenic liver abscess and pylephlebitis in an adult patient.</jats:p

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Hindawi Publishing CorporationCase Reports in HepatologyVolume 2011, Article ID 536167, 3 pagesdoi:10.1155/2011/536167Case ReportPropionibacterium acnes PyogenicLiver Abscess and PylephlebitisArash Poursina and Sharon WeissmanDepartment of Infectious Diseases, University of South Carolina, 2 Medical Park, Suite 205, Columbia, SC 29203, USACorrespondence should be addressed to Arash Poursina, arash.poursina@uscmed.sc.eduReceived 8 July 2011; Accepted 15 August 2011Academic Editors: C. Miyabayashi, G. Papatheodoridis, and F. Pe´rez Rolda´nCopyright © 2011 A. Poursina and S. Weissman. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.Reported is an unusual case of pyogenic liver abscess and septic thrombophlebitis of the portal vein in a 44-year-old male causedby Propionibacterium acnes successfully managed with a combination of percutaneous drainage and antimicrobial therapy. To thebest of our knowledge, this is the first report of this bacterium isolated in pure culture as the sole etiologic organism of pyogenicliver abscess and pylephlebitis in an adult patient.1. IntroductionPyogenic liver abscess is an infrequent infection with an inci-dence of 2.3–3.6 per 100,000 population [1, 2]. Although theincidence of pyogenic liver abscess appears to be increasingmorbidity and mortality due to this condition has declineddue to improved diagnostic and treatment modalities [3].Pyogenic liver abscess can be a significant source of mor-bidity and mortality particularly if accompanied by septicthrombophlebitis of the portal system.Although the source of the pyogenic liver abscess may becryptogenic, the majority of cases result from biliary tractdisease or spread followed by trauma and colonic disease[4, 5]. Enteric gram-negative bacilli are the most commonorganism involved, followed by streptococci species andanaerobic organism. Mixed infections are not uncommon[4, 5]. Septic thrombophlebitis has been reported to be thesource of infection in thirteen percent of the cases [6]. Septicthrombophlebitis of the portal vein typically occurs in thesetting of suppurative infection in the regions drained by thetributaries of the portal vein which includes the abdominalpart of the gastrointestinal tract except the lower part ofrectum [7].We describe an unusual case of pyogenic liver abscesscaused by Propionibacterium acnes with associated septicthrombophlebitis of the portal vein.2. Case ReportA 44-year-old male with a history of alcohol abuse presentedwith a one-week history of lethargy, confusion, stupor,abdominal pain, and jaundice. He had been seen in theemergency facility on several occasions during the precedingweek. He was noted to have WBC count of 44,000 cell/µL.Initial computed tomography scan of the abdomen showed asuspected pancreaticmass, andmultiple liver lesions were feltto be of metastatic origin. He was referred to our facility forfurther evaluation. On arrival at our facility, he was noted tohave a temperature of 100.7 F and a heart rate of 125/minute.On examination, he was jaundiced, stuporous, and confused.His abdomen was distended and diﬀusely tender. He hadgrossly edematous lower extremities. His laboratory bloodwork included a WBC 26.2 × 103/µL with 80% PMN,hemoglobin 9.8 g/dL, hematocrit 26.9%, and platelet countof 297 × 103/µL. His liver enzymes were elevated with AST422U/L, ALT 106U/L, and Alkaline phosphatase 373U/L.His plasma ammonia was 56UMOL/L. His initial bloodcultures, screening for viral hepatitis and alpha fetoproteinand CEA were all unrevealing. A repeat CT scan was reportedto be strongly favoring extensive hepatic metastasis with apossible primary in the head of the pancreas (Figure 1).He underwent a CT-guided percutaneous biopsy. Histologyrevealed severe acute inflammatory with fibropurulent debris2 Case Reports in HepatologyFigure 1: CT scan of the abdomen highly suspicious for multiplehepatic metastases.and no evidence of malignancy. A magnetic resonanceimaging of his liver later showed rapid evolution of alarge subcapsular abscess in the right lobe (Figure 2) andcoalescence of the predominant lesions in the left liverlobe (Figures 2 and 3). His pancreatic abnormality wasconsistent with chronic pancreatitis. Doppler ultrasound ofhis portal vein was consistent with complete thrombosis.Computed-tomographic-guided percutaneous drainage ofthe large subcapsular abscess was performed under asepticconditions. While awaiting the culture results, he was startedon ceftriaxone and metronidazole. He was also startedon coumadin for the management of his pylephlebitis.The percutaneous drainage gram stain was positive forpredominantly intracellular gram-positive bacilli that couldnot be successfully grown in culture. His antibiotics werechanged to imipenem and trimethoprim/sulfamethoxazole.An accidental dislodgement of his drain and the enlargementof his abscesses led to a second computed-tomography-guided percutaneous drainage a week later and a similarlypositive gram stain but this time the cultures grew Propi-onibacterium acnes. His antibiotic coverage was narrowed toamoxicillin/clavulanic acid at 875/125mg every 8 hours. Heimproved with antibiotics and percutaneous drainage of theabscess with complete resolution of his lesions on subsequentimaging studies and improvement in his functional statusand laboratory parameters. Unfortunately, our patient dieddue to an unrelated cause several months later.3. DiscussionWe report an unusual case of Propionibacterium acnes asthe etiologic agent for hepatic pyogenic liver abscess withassociated thrombosis of the portal vein. To the best ofour knowledge, there have only been three other cases ofPropionibacterium acnes associated liver abscess in two of thecases this organism was part of a polymicrobial infection.The first case reported was in a four-year-old girl whodeveloped a liver abscess four weeks after abdominal trauma.Figure 2: MRI of the abdomen with a large subcapsular abscess.Figure 3: MRI of the abdomen with a large subcapsular abscess andcoalescence of hepatic lesions into larger abscesses.Propionibacterium acnes was isolated from the abscess andblood cultures [8]. The second case was reported in a 48-year-old man who intraoperatively was discovered to havea toothpick within the abscess. His intraoperative culturesgrew Streptococcus viridians, Bacteroides melaninogenicus,and Propionibacterium [9]. The last case was reported in a52-year-old woman with a mixed bacterial liver abscess. Per-cutaneous cultures grew Actinomyces Israeli, Capnocytophagaspp., and Propionibacterium acnes. She had an intrauterinedevice in place. This was presumptively the source of theinfection [10].Propionibacterium acnes is a commensal of human skinimplicated in acne vulgaris. P. acnes has been implicatedin cases of osteomyelitis of the spine, the skull, joints, andCNS infections and abscess formations often as the result ofsurgical interventions and postsurgical complications [11–13]. It is often associated with the presence of foreign bodiessuch as ventricular peritoneal shunts, trauma, malignancy,Case Reports in Hepatology 3and immunodeficient conditions such as diabetes andimmunosuppressive therapies [13].This current case is diﬀerent than the previous reportsas P. acnes was isolated as the sole organism; there was nota foreign body involved or an antecedent trauma. Also, thecurrent case was complicated by portal vein thrombosis.We postulate that septic thrombophlebitis of the portalvein was the source of the infection, although it is possiblethat Propionibacterium acnes was introduced iatrogenicallyduring the initial needle aspiration. Arguments against aniatrogenic source in this case include (1) the multiplelesions seen on earlier imaging studies predated any invasiveprocedure, (2) the same lesions appeared to have coalesced toform larger abscesses and not all of them had been biopsied,(3) the presence of pylephlebitis as the source of the infectiveemboli in the liver prior to the percutaneous biopsies, and(4) relative impaired immunity of our patient due to hisextensive history of alcohol abuse.This case serves as a reminder that, although rare,Propionibacterium acnes may be a cause of liver abscess.P. acnes may be an under recognized etiology due todiﬃculties in isolating the organism as it requires anaerobicmedia and a longer duration of incubation. The correctidentification of this organism can help in a more directednarrow spectrum antibiotic management. Lastly, adequateaseptic precautions must be adhered to during percutaneousprocedures to prevent introduction of skin commensals intodeeper structures.References[1] L. Meddings, R. P. Myers, J. Hubbard et al., “A population-based study of pyogenic liver abscesses in the united states:incidence, mortality, and temporal trends,” American Journalof Gastroenterology, vol. 105, no. 1, pp. 117–124, 2010.[2] A. H.Mohsen, S. T. Green, R. C. Read, andM.W.McKendrick,“Liver abscess in adults: ten years experience in a UK centre,”QJM, vol. 95, no. 12, pp. 797–802, 2002.[3] C. J. Huang, H. A. Pitt, P. A. Lipsett et al., “Pyogenic hepaticabscess: changing trends over 42 years,” Annals of Surgery, vol.223, no. 5, pp. 600–609, 1996.[4] I. Brook and E. H. Frazier, “Microbiology of liver and spleenabscesses,” Journal of Medical Microbiology, vol. 47, no. 12, pp.1075–1080, 1998.[5] J. Rahimian, T. Wilson, V. Oram, and R. S. Holzman, “Pyo-genic liver abscess: recent trends in etiology and mortality,”Clinical Infectious Diseases, vol. 39, no. 11, pp. 1654–1659,2004.[6] F. S. Hill Jr. and H. L. Laws, “Pyogenic hepatic abscesses,”American Surgeon, vol. 48, no. 2, pp. 49–53, 1982.[7] R. M. Plemmons, D. P. Dooley, and R. N. Longfield, “Septicthrombophlebitis of the portal vein (pylephlebitis): diagnosisand management in the modern era,” Clinical InfectiousDiseases, vol. 21, no. 5, pp. 1114–1120, 1995.[8] H. H. Balfour and S. L. Minken, “Liver abscess due tocorynebacterium acnes. Diphtheroid as pathogen,” ClinicalPediatrics, vol. 10, no. 1, pp. 55–58, 1971.[9] V. Drnovsek, D. Fontanez-Garcia, M. N. Wakabayashi, andB. M. Plavsic, “Gastrointesitnal case of the day. Pyogenicliver abscess caused by perforation by a swallowed woodentoothpick,” Radiographics, vol. 19, no. 3, pp. 820–822, 1999.[10] R. Palacios Mun˜oz, M. Abarca Costalago, C. Arana Romero,and J. Santos Gonza´lez, “Suppurative hepatic lesion withextension to soft tissues,” Revista Clinica Espanola, vol. 206,no. 8, pp. 397–398, 2006.[11] R. Haidar, M. Najjar, A. D. Boghossian, and Z. Tabbarah, “Pro-pionibacterium acnes causing delayed postoperative spineinfection: review,” Scandinavian Journal of Infectious Diseases,vol. 42, no. 6-7, pp. 405–411, 2010.[12] J. M. Ramos, J. Esteban, and F. Soriano, “Isolation of Propi-onibacterium acnes from central nervous system infections,”Anaerobe, vol. 1, no. 1, pp. 17–20, 1995.[13] I. Brook and E. H. Frazier, “Infections caused by Propionibac-terium species,” Reviews of Infectious Diseases, vol. 13, no. 5,pp. 819–822, 1991.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

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