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Pyomyositis and hepatic abscess in association with aeromonas hydrophila sepsis
Pyomyositis and Hepatic Abscess in Association with Aeromonas hydrophila Sepsis
ROBERT A. KRATZKE, M.D. DOUGLAS T. GOLENBOCK, M.D. Madison,
Wisconsin
This report describes a patient with chronic liver disease in whom Aeromonas hydrophila sepsis developed followtng ingestion of fresh lake water. A hepatic abscess and bilateral calf pyomyositis, an extremely rare and previously fatal complication of A. hydrophila septicemia, subsequently developed. The patient recovered following bilateral fasciotomies and systemic antibiotic therapy with gentamicin and trimethoprim/sulfamethoxazole. No previous survivors of A. hydrophila pyomyositis secondary to metastatic infection have been described. A discussion of these rare sequelae of A. hydrophila septicemia and their effective management is included. Aeromonas hydrophila is the etiologic agent responsible for a small percentage of acute self-limited diarrhea1 syndromes [ 11. Rarely, it is the cause of sepsis and subsequent metastatic infection [2]. Disseminated infection in a patient with A. hydrophila bacteremia can be manifested by abdominal abscesses [2-41, meningitis [5], or hepatobiliary infections [2,3]. The first reported case of A. hydrophila septicemia involved a patient with disseminated infection and pyomyositis [6]. This rarely reported complication of A. hydrophila septicemia has been documented at autopsy in three previous oases [6-81. We herein present a Case of A. hydrophila bacteremia, pyomyositis, and hepatic abscess in which the patient survived following diagnosis and appropriate therapy.
CASE REPORT
From the Department of Internal Medicine, and the Division of infectious Diseases, Clinical Sciences Center, University of Wisconsin Hospital and Clinics, Madison, Wisconsin. Requests for reprints should be addressed to Dr. Douglas T. Golenbock, Division of Infectious Diseases, H 4/ 572 Clinical Sciences Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, Wisconsin 53792. Manuscript submitted September 15, 1986, and accepted January 13, 1987.
A 4%year-old man with a history of alcohol abuse, and a recent fall into a freshwater lake, was admitted to a community hospital with three days of diarrhea, nausea, vomiting, rigors, and bilateral calf pain. Physical examination revealed a febrile (39.4OC) cachectic middle-aged man with minimal abdominal tenderness and distension. Despite the patient’s complaint of severe leg pain, there was only moderate tenderness upon palpation of his calves. Treatment with cefoxitin was begun on the day of admission. A. hydrophila grew in blood culture specimens sensitive to cefoxitin and gentamicin. The patient’s total bilirubin level rose from 3.3 mg/dl (normal, 0.6 to 1.7 mg/dl) to 13.5 mg/dl by the fourth hospital day. Computed tomographic scanning of the abdomen demonstrated multiple hypodense areas involving both lobes of the liver, cholelithiasis without obstruction, and moderate ascites. On the fifth day of hospitalization, the patient underwent exploratory laparotomy and cholecystojejunostomy. Liver biopsy specimens revealed moderate cirrhosis and multiple confluent microabscesses, the culture specimens of which grew A. hydrophila. Gentamicin was added to the patient’s antibiotic regimen. Over the next week, the bilirubin level decreased to 2.1 mgldl, but he continued to report fevers, chills, and bilateral leg pain. His temperature rose to 39.3’C rectally, and he was transferred to University of Wisconsin Hospital and Clinics (Madison, Wisconsin) on the ninth postoperative day.
August 1987
The
American Journal of Medicine
Volume
83
347
AEROMONAS
HYDROPHILA
PYOMYOSITIS
AND
HEPATIC
ABSCESS-KRATZKE
Examination on admission revealed an ill-appearing white man with a temperature of 36.4OC orally, blood pressure of 120160 mm Hg, a respiratory rate of 24 breaths/ minute, and a pulse rate of 120 beats/minute. The abdomen was distended and mildly tender with diminished bowel sounds. The liver measured 10 cm. Examination of the extremities revealed slight erythema and l+ pretibial edema with minimal calf tenderness. Initial laboratory data included a white blood cell count of 13,200/mm3 with 74 percent polymorphonuclear leukocytes, 12 percent band forms, 13 percent lymphocytes, and 1 percent monocytes. The serum lactic dehydrogenase level was 164 units/liter (normal range, 90 to 200 units/liter), the gamma glutamyl transferase level was 98 units/liter (normal range, 0 to 65 units/liter), and the serum glutamic oxaloacetic transaminase level was 52 units/liter (normal range, 0 to 50 units/ liter). The total bilirubin level was 2.1 mg/dl (normal range, 0.0 to 1.4 mg/dl). Ascitic fluid was serous with a white blood cell count of 3,000/mm3 (50 percent polymorphonuclear leukocytes, 32 percent lymphocytes, 8 percent plasma cells, 9 percent phagocytic cells); results of cultures for bacteria and acid-fast bacilli were negative. The following day, the patient underwent sugery, and a bile leak was corrected. Results of intraoperative cholangiography were negative. Additionally, a hepatlc abscess of the left lobe was drained. Gram’s stain and results of cultures of the liver abscess drainage were negative. Postoperatively, the patient’s course was complicated by intermittent fevers and the adult respiratory distress syndrome. By the fifth postoperative day, the white blood cell count was 15,900/mm3. The following day, the patient’s calves were noted to be erythematous and markedly tender. Needle aspiration was performed on the left calf, and a copious amount of frank pus was aspirated. Gram’s stain revealed many polymorphonuclear leukocytes and occasional gram-negative bacilli consistent with A. hydrophila. Subsequently, the patient underwent bilateral fasciotomies revealing gross pyomyositis of the anterior compartment of both lower extremities. Results of abscess cultures were negative. The patient recovered completely over the course of six weeks following therapy with gentamicin and trimethoprim/sulfamethoxazole. COMMENTS This case demonstrates two interesting and rare complications of A. hydrophila bacteremia: pyomyositis and hepatic abscess. The prominent initial clinical features of this case were diarrhea, gastrointestinal distress, and calf pain followed by gram-negative septicemia. Bacteremia, pyomyositis, and a hepatic abscess were subsequently documented. Culture specimens of the muscle abscesses showed no growth, but Gram’s stain revealed organisms consistent with A. hydrophila. Interestingly, the first reported human infection with A. hydrophila was also a case with disseminated infection, including pyomyositis [6]. Two subsequent fatal cases have been reported, Only one of which demonstrated organisms within the tissue [7,8]. Disseminated infection with A. hydrophila is seen al348
August
1987
The American
Journal
of Medicine
Volume
and
GOLENBOCK
most exclusively in patients with either underlying rnalignancy [9] or chronic liver disease [2,3]. Our patient had a history of alcoholic cirrhosis. Additionally, our patient had a hepatic abscess. In two recent series covering a total of 71 oases of liver abscesses at two institutions, none involved infection with A. hydrophila [ 10, ii]. Patients with liver disease may be predisposed to pyogenic hepatic abscesses due to A. hydrophila. Another such case has recently been reported [4]. The prodrome of a diarrhea1 illness is commonly seen in A. hydrophila sepsis [2,12]. Although many authors believe that the organism is acquired through incidental contact and ingestion of water from lakes or ponds, there is little epidemiologic evidence supporting this hypothesis. In a recent review of 20 oases of A. hydrophila intestinal infections, evidence of surface water exposure was found in only one patient [I]. Although our patient had a history of lake water ingestion 10 days prior to the development of clinically significant disease, such exposure is found to be the exception rather than the rule in patients with A. hydrophila bacteremia [2,9,13]. In a recent review of the literature, the actual incidence of previous outdoor exposure in patients with A. hydrophila bacteremia was only 9 percent [9]. Pyomyositis occurs in the setting of disseminated infection with a variety of organisms [ 131. Metastatic pyomyositis following bacteremia with A. hydrophila, however, is a rare clinical entity. Since the first reported ease of A. hydrophila infection, a patient with septicemia and metastatic pyomyositis, two other oases have been reported, only one of which demonstrated any organisms within muscle tissue [6-81. None of the previous patients survived; the diagnosis of pyomyositis was confirmed at autopsy in all three cases. Our patient survived without any permanent sequelae following bilateral fasciotomies combined with systemic administration of antibiotics, the treatment of choice for pyomyositis [ 131. Localized soft-tissue infections with A. hydrophila following penetrating traumatic injuries are relatively common and respond well to therapy with systemic antibiotics and local debridement [2,14,15]. These infections are often associated with marked inflammation and local tissue destruction. Pyomyositis is common, leading some authors to conclude that A. hydrophila possesses mUSCle tropism [2]. Virtually all isolates of Aeromonas are sensitive to aminoglycosides; trimethoprim/sulfamethoxazole, moxalactam, chloramphenicol, and tetracycline may also be efficacious [ 131. In summary, we present a case of A. hydrophila sepsis with hepatic abscess and pyomyositis, a rare and previously fatal complication of A. hydrophila septicemia. Bacteremic patients with liver disease may be prone to the development of hepatic abscess. Patients with A. hydrophila bacteremia and muscle pain should be evaluated for occult pyomyositis. 83
AEROMONAS
HYDROPHILA
PYOMYOSITIS
AND
HEPATIC
ABSCESS-KRATZKE
and
GOLENBOCK
REFERENCES 1.
2.
3. 4. 5.
6.
7.
8.
Agger WA, McCormick JD, Gurwith MJ: Clinical and microbiological features of aeromonas hydrophila-associated diarrhea. J Clin Microbial 1985; 21: 909-913. Davis WA, Kane JG, Garagusi VF: Human Aeromonas infections: a review of the literature and a case report of endocarditis. Medicine (Baltimore) 1978; 57: 267-277. Washington JA: Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med 1972; 76: 611-614. Colaco CP: Aeromonas hydrophila liver abscess (letter). Lancet 1982; I: 680. Ellison RT, Mostow SR: Pyogenic meningitis manifesting during therapy for Aeromonas hydrophila sepsis. Arch Intern Med 1984; 144: 2078-2079. Hill KR, Caselitz FH, Moody LN: A case of acute metastatic myositis caused by a new organism of the family: Pseudomonadaceae. West Indian Med J 1954; 3: 9-l 1. Shilkin KB, Annear DI, Rowett LR, Laurence BH: Infection due to Aeromonas hydrophila. Med J Aust 1968; 1: 351353. Bulger R, Sherris J: The clinical significance of Aeromonas
August
9.
10. 11.
12.
13.
14. 15.
1987
hydrophila. Arch Intern Med 1966; 118: 562-564. Harris RL, Fainstein V, Eltin L, Hopfer RL, Bodey GP: Bacteremia caused by Aeromonas hydrophila in hospitalized cancer patients. Rev Infect Dis 1985; 7: 314-320. Perra MR, Kirk A, Noone P: Presentation, diagnosis, and management of liver abscess. Lancet 1980; I: 629-632. McDonald Ml, Corey GR, Gallis HA, Durack DT: Single and multiple pyogenic liver abscesses: natural history, diagnosis and treatment, with emphasis on percutaneous drainage. Medicine (Baltimore) 1984; 83: 291-302. Stephen S, Rao KNA, Kumar MS, lndrani R: Human infection with Aeromonas species: varied clinical manifestations (letter). Ann Intern Med 1975; 83: 368-369. Mandell GL, Douglas RG, Bennett JE, eds: Principles and practices of infectious diseases, 2nd ed. New York: John Wiley and Sons, 1985; 613-614. McCracken AW, Barkley R: Isolation of Aeromonas species from clinical sources. J Clin Pathol 1972; 25: 970-975. Phillips JA, Bernhardt HE, Rosenthal SG: Aeromonas hydrophila infections. Pediatrics 1974; 53: 110-l 11.
The
American
Journal
of Medicine
Volume
83
349
ROBERT A. KRATZKE, M.D. DOUGLAS T. GOLENBOCK, M.D. Madison,
Wisconsin
This report describes a patient with chronic liver disease in whom Aeromonas hydrophila sepsis developed followtng ingestion of fresh lake water. A hepatic abscess and bilateral calf pyomyositis, an extremely rare and previously fatal complication of A. hydrophila septicemia, subsequently developed. The patient recovered following bilateral fasciotomies and systemic antibiotic therapy with gentamicin and trimethoprim/sulfamethoxazole. No previous survivors of A. hydrophila pyomyositis secondary to metastatic infection have been described. A discussion of these rare sequelae of A. hydrophila septicemia and their effective management is included. Aeromonas hydrophila is the etiologic agent responsible for a small percentage of acute self-limited diarrhea1 syndromes [ 11. Rarely, it is the cause of sepsis and subsequent metastatic infection [2]. Disseminated infection in a patient with A. hydrophila bacteremia can be manifested by abdominal abscesses [2-41, meningitis [5], or hepatobiliary infections [2,3]. The first reported case of A. hydrophila septicemia involved a patient with disseminated infection and pyomyositis [6]. This rarely reported complication of A. hydrophila septicemia has been documented at autopsy in three previous oases [6-81. We herein present a Case of A. hydrophila bacteremia, pyomyositis, and hepatic abscess in which the patient survived following diagnosis and appropriate therapy.
CASE REPORT
From the Department of Internal Medicine, and the Division of infectious Diseases, Clinical Sciences Center, University of Wisconsin Hospital and Clinics, Madison, Wisconsin. Requests for reprints should be addressed to Dr. Douglas T. Golenbock, Division of Infectious Diseases, H 4/ 572 Clinical Sciences Center, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, Wisconsin 53792. Manuscript submitted September 15, 1986, and accepted January 13, 1987.
A 4%year-old man with a history of alcohol abuse, and a recent fall into a freshwater lake, was admitted to a community hospital with three days of diarrhea, nausea, vomiting, rigors, and bilateral calf pain. Physical examination revealed a febrile (39.4OC) cachectic middle-aged man with minimal abdominal tenderness and distension. Despite the patient’s complaint of severe leg pain, there was only moderate tenderness upon palpation of his calves. Treatment with cefoxitin was begun on the day of admission. A. hydrophila grew in blood culture specimens sensitive to cefoxitin and gentamicin. The patient’s total bilirubin level rose from 3.3 mg/dl (normal, 0.6 to 1.7 mg/dl) to 13.5 mg/dl by the fourth hospital day. Computed tomographic scanning of the abdomen demonstrated multiple hypodense areas involving both lobes of the liver, cholelithiasis without obstruction, and moderate ascites. On the fifth day of hospitalization, the patient underwent exploratory laparotomy and cholecystojejunostomy. Liver biopsy specimens revealed moderate cirrhosis and multiple confluent microabscesses, the culture specimens of which grew A. hydrophila. Gentamicin was added to the patient’s antibiotic regimen. Over the next week, the bilirubin level decreased to 2.1 mgldl, but he continued to report fevers, chills, and bilateral leg pain. His temperature rose to 39.3’C rectally, and he was transferred to University of Wisconsin Hospital and Clinics (Madison, Wisconsin) on the ninth postoperative day.
August 1987
The
American Journal of Medicine
Volume
83
347
AEROMONAS
HYDROPHILA
PYOMYOSITIS
AND
HEPATIC
ABSCESS-KRATZKE
Examination on admission revealed an ill-appearing white man with a temperature of 36.4OC orally, blood pressure of 120160 mm Hg, a respiratory rate of 24 breaths/ minute, and a pulse rate of 120 beats/minute. The abdomen was distended and mildly tender with diminished bowel sounds. The liver measured 10 cm. Examination of the extremities revealed slight erythema and l+ pretibial edema with minimal calf tenderness. Initial laboratory data included a white blood cell count of 13,200/mm3 with 74 percent polymorphonuclear leukocytes, 12 percent band forms, 13 percent lymphocytes, and 1 percent monocytes. The serum lactic dehydrogenase level was 164 units/liter (normal range, 90 to 200 units/liter), the gamma glutamyl transferase level was 98 units/liter (normal range, 0 to 65 units/liter), and the serum glutamic oxaloacetic transaminase level was 52 units/liter (normal range, 0 to 50 units/ liter). The total bilirubin level was 2.1 mg/dl (normal range, 0.0 to 1.4 mg/dl). Ascitic fluid was serous with a white blood cell count of 3,000/mm3 (50 percent polymorphonuclear leukocytes, 32 percent lymphocytes, 8 percent plasma cells, 9 percent phagocytic cells); results of cultures for bacteria and acid-fast bacilli were negative. The following day, the patient underwent sugery, and a bile leak was corrected. Results of intraoperative cholangiography were negative. Additionally, a hepatlc abscess of the left lobe was drained. Gram’s stain and results of cultures of the liver abscess drainage were negative. Postoperatively, the patient’s course was complicated by intermittent fevers and the adult respiratory distress syndrome. By the fifth postoperative day, the white blood cell count was 15,900/mm3. The following day, the patient’s calves were noted to be erythematous and markedly tender. Needle aspiration was performed on the left calf, and a copious amount of frank pus was aspirated. Gram’s stain revealed many polymorphonuclear leukocytes and occasional gram-negative bacilli consistent with A. hydrophila. Subsequently, the patient underwent bilateral fasciotomies revealing gross pyomyositis of the anterior compartment of both lower extremities. Results of abscess cultures were negative. The patient recovered completely over the course of six weeks following therapy with gentamicin and trimethoprim/sulfamethoxazole. COMMENTS This case demonstrates two interesting and rare complications of A. hydrophila bacteremia: pyomyositis and hepatic abscess. The prominent initial clinical features of this case were diarrhea, gastrointestinal distress, and calf pain followed by gram-negative septicemia. Bacteremia, pyomyositis, and a hepatic abscess were subsequently documented. Culture specimens of the muscle abscesses showed no growth, but Gram’s stain revealed organisms consistent with A. hydrophila. Interestingly, the first reported human infection with A. hydrophila was also a case with disseminated infection, including pyomyositis [6]. Two subsequent fatal cases have been reported, Only one of which demonstrated organisms within the tissue [7,8]. Disseminated infection with A. hydrophila is seen al348
August
1987
The American
Journal
of Medicine
Volume
and
GOLENBOCK
most exclusively in patients with either underlying rnalignancy [9] or chronic liver disease [2,3]. Our patient had a history of alcoholic cirrhosis. Additionally, our patient had a hepatic abscess. In two recent series covering a total of 71 oases of liver abscesses at two institutions, none involved infection with A. hydrophila [ 10, ii]. Patients with liver disease may be predisposed to pyogenic hepatic abscesses due to A. hydrophila. Another such case has recently been reported [4]. The prodrome of a diarrhea1 illness is commonly seen in A. hydrophila sepsis [2,12]. Although many authors believe that the organism is acquired through incidental contact and ingestion of water from lakes or ponds, there is little epidemiologic evidence supporting this hypothesis. In a recent review of 20 oases of A. hydrophila intestinal infections, evidence of surface water exposure was found in only one patient [I]. Although our patient had a history of lake water ingestion 10 days prior to the development of clinically significant disease, such exposure is found to be the exception rather than the rule in patients with A. hydrophila bacteremia [2,9,13]. In a recent review of the literature, the actual incidence of previous outdoor exposure in patients with A. hydrophila bacteremia was only 9 percent [9]. Pyomyositis occurs in the setting of disseminated infection with a variety of organisms [ 131. Metastatic pyomyositis following bacteremia with A. hydrophila, however, is a rare clinical entity. Since the first reported ease of A. hydrophila infection, a patient with septicemia and metastatic pyomyositis, two other oases have been reported, only one of which demonstrated any organisms within muscle tissue [6-81. None of the previous patients survived; the diagnosis of pyomyositis was confirmed at autopsy in all three cases. Our patient survived without any permanent sequelae following bilateral fasciotomies combined with systemic administration of antibiotics, the treatment of choice for pyomyositis [ 131. Localized soft-tissue infections with A. hydrophila following penetrating traumatic injuries are relatively common and respond well to therapy with systemic antibiotics and local debridement [2,14,15]. These infections are often associated with marked inflammation and local tissue destruction. Pyomyositis is common, leading some authors to conclude that A. hydrophila possesses mUSCle tropism [2]. Virtually all isolates of Aeromonas are sensitive to aminoglycosides; trimethoprim/sulfamethoxazole, moxalactam, chloramphenicol, and tetracycline may also be efficacious [ 131. In summary, we present a case of A. hydrophila sepsis with hepatic abscess and pyomyositis, a rare and previously fatal complication of A. hydrophila septicemia. Bacteremic patients with liver disease may be prone to the development of hepatic abscess. Patients with A. hydrophila bacteremia and muscle pain should be evaluated for occult pyomyositis. 83
AEROMONAS
HYDROPHILA
PYOMYOSITIS
AND
HEPATIC
ABSCESS-KRATZKE
and
GOLENBOCK
REFERENCES 1.
2.
3. 4. 5.
6.
7.
8.
Agger WA, McCormick JD, Gurwith MJ: Clinical and microbiological features of aeromonas hydrophila-associated diarrhea. J Clin Microbial 1985; 21: 909-913. Davis WA, Kane JG, Garagusi VF: Human Aeromonas infections: a review of the literature and a case report of endocarditis. Medicine (Baltimore) 1978; 57: 267-277. Washington JA: Aeromonas hydrophila in clinical bacteriologic specimens. Ann Intern Med 1972; 76: 611-614. Colaco CP: Aeromonas hydrophila liver abscess (letter). Lancet 1982; I: 680. Ellison RT, Mostow SR: Pyogenic meningitis manifesting during therapy for Aeromonas hydrophila sepsis. Arch Intern Med 1984; 144: 2078-2079. Hill KR, Caselitz FH, Moody LN: A case of acute metastatic myositis caused by a new organism of the family: Pseudomonadaceae. West Indian Med J 1954; 3: 9-l 1. Shilkin KB, Annear DI, Rowett LR, Laurence BH: Infection due to Aeromonas hydrophila. Med J Aust 1968; 1: 351353. Bulger R, Sherris J: The clinical significance of Aeromonas
August
9.
10. 11.
12.
13.
14. 15.
1987
hydrophila. Arch Intern Med 1966; 118: 562-564. Harris RL, Fainstein V, Eltin L, Hopfer RL, Bodey GP: Bacteremia caused by Aeromonas hydrophila in hospitalized cancer patients. Rev Infect Dis 1985; 7: 314-320. Perra MR, Kirk A, Noone P: Presentation, diagnosis, and management of liver abscess. Lancet 1980; I: 629-632. McDonald Ml, Corey GR, Gallis HA, Durack DT: Single and multiple pyogenic liver abscesses: natural history, diagnosis and treatment, with emphasis on percutaneous drainage. Medicine (Baltimore) 1984; 83: 291-302. Stephen S, Rao KNA, Kumar MS, lndrani R: Human infection with Aeromonas species: varied clinical manifestations (letter). Ann Intern Med 1975; 83: 368-369. Mandell GL, Douglas RG, Bennett JE, eds: Principles and practices of infectious diseases, 2nd ed. New York: John Wiley and Sons, 1985; 613-614. McCracken AW, Barkley R: Isolation of Aeromonas species from clinical sources. J Clin Pathol 1972; 25: 970-975. Phillips JA, Bernhardt HE, Rosenthal SG: Aeromonas hydrophila infections. Pediatrics 1974; 53: 110-l 11.
The
American
Journal
of Medicine
Volume
83
349