Pyogenic Liver Abscess Presenting With Diabetic Ketoacidosis

Abstract

Pyogenic liver abscess (PLA) is a rare complication of diabetes, associated with poor glycemic control, and can potentially be life-threatening. We present a case of resistant diabetic ketoacidosis found to have underlying PLA.CASE PRESENTATION: 49-year-old male with past medical history of insulin-dependent diabetes mellitus presented with several days of malaise, nausea, and vomiting. Vital signs were notable for tachycardia and tachypnea, with physical exam notable for mild epigastric tenderness. Labwork was notable for white blood cell count 24.7 thou/uL with neutrophilic predominance, blood glucose of 496 with increased anion gap (30) metabolic acidosis (pH 7.17), beta-hydroxybutyric acid 11.10 mmol/L, lactic acid 4.9 mmol/L, and ketonuria. Transaminitis was also noted: aspartate aminotransferase (AST) 81 U/L, alanine aminotransferase (ALT) 74 U/L, and alkaline phosphatase 147 U/L. He was admitted for management of diabetic ketoacidosis requiring frequent accu-checks and an insulin drip. His blood sugars were hard to control and given persistent leukocytosis, imaging was obtained, with computed tomography (CT) of chest/abdomen/pelvis showed confluent liver masses, most compatible with liver abscesses. Liver ultrasound confirmed the diagnosis of multiple liver abscesses, therefore the patient was placed on broad-spectrum antibiotics. A thorough workup was done to determine the etiology of the abscesses, however, it was unremarkable; therefore, the etiology was thought to most likely be suppressed immunity secondary to poor diabetic control, with hemoglobin A1C of 14%, in addition to elevated blood sugars for a prolonged period leading to abscess formation. Subsequently, 4/4 blood cultures were consistent with Escherichia coli (E. coli) bacteremia. He underwent drainage of the abscesses with placement of 2 pigtail drainage catheters; culture of the fluid was also positive for E. coli infection. With control of the infection, blood sugar control was also achieved, and the patient was transitioned to an insulin regimen prior to discharge with oral antibiotics and extensive diabetic education.DISCUSSION: PLA is a supportive infection involving the hepatic parenchyma, mostly seen in Asian countries, with its incidence in the USA very rare, seen in about 3.59 per 100,000 cases [1]. Risk factors include autoimmune disease, cholangitis, malignancy, and diabetes mellitus among others, with recent studies showing increased morbidity in patients with PLA secondary to diabetes. Klebsiella pneumonia is the organism most commonly found to be the culprit, followed by E. coli [2]. While the bacteria usually remains confined to the liver, the risk for bacteremia is increased in patients with uncontrolled diabetes [1].CONCLUSIONS: Clinicians should maintain a high clinical suspicion for PLA, especially in those presenting with DKA and concurrent transaminitis as early treatment can improve outcomes.