liver abscess case report and literature review

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Klebsiella Pneumoniae Liver Abscess: a Case Report and Review of Literature

Faisal kamal, george williams, muhammad ali khan, dipen kadaria.

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Faisal Kamal [email protected]

Corresponding author.

Received 2016 Jun 15; Accepted 2017 Jan 10; Collection date 2017 Jan.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Klebsiella pneumoniae (K.pneumoniae) is a known cause of pyogenic liver abscess (PLA) in the absence of hepatobiliary disease. In settings of hepatic infection, it has also been known to cause disseminated infections including meningitis and endopthalmitis. Several groups of patients are particularly susceptible to infection, including patients with diabetes mellitus, those from Southeast Asia and those with the preexisting hepatobiliary disease. We present a case of K.pneumoniae PLA with bacteremia. A 39-year-old Vietnamese male with no previous medical history who presented with complaints of abdominal pain, nausea, vomiting, diarrhea and fever. A computed tomography (CT) of the abdomen showed a large complex mass in the right lobe of the liver with multiple septations. Over course of hospitalization, the patient developed acute respiratory failure and was monitored in medical intensive care unit (MICU). Blood cultures grew K. pneumonia. The patient was treated with intravenous ceftriaxone and the abscess was drained by interventional radiology. After appropriate management, he progressed well during his hospital course and was eventually discharged from the hospital. K. pneumonia PLA had previously been an endemic disease in Southeast Asia, however, with a highly mobile patient population, it is now seen throughout the world and should be in the differential of patients who present with solitary liver mass in the setting of sepsis.

Keywords: hepatic abscesses

Introduction

Klebsiella pneumoniae is a gram-negative organism that can cause pyogenic liver abscess (PLA) in the absence of hepatobiliary disease. Diabetics are at increased risk of this infection. Some patients with Klebsiella liver abscess can develop metastatic infections including endophthalmitis, meningitis, brain abscess, septic pulmonary emboli, lung abscess, splenic abscess, osteomyelitis, etc. It has been found to be a common cause of liver abscess in Taiwan. However, recently there has been the change in the trend of this infection in the United States [ 1 ]. And now it is one of the common causes of PLA in the United States. We present a case of Klebsiella liver abscess with bacteremia. Informed consent was obtained from the patient for this study.

Case presentation

A 39-year-old Vietnamese male with no significant past medical history presented to a large urban emergency department with complaints of sharp 5/10 right upper quadrant abdominal pain, nausea, vomiting, fever and chills. The patient stated that he had been in his previous state of good health until approximately three days prior to presentation when his symptoms became debilitating. He worked at a local nail salon and stated that several co-workers were exhibiting cold like symptoms. His travel history was significant for the trip back to Vietnam within the last year but stated that his travels were uneventful and he did not remember feeling ill during that time. Review of systems was significant for the aforementioned symptoms in addition to loss of appetite with early satiety and one previous episode of streaky hemoptysis several days prior to presentation. In the emergency department, basic laboratory showed that he had an increased anion gap to 18, an acute kidney injury with a serum creatinine of 1.4, alkaline phosphatase 172, AST 81, ALT 107, ferritin 4,680 and a white blood cell count of 10.5.

A computed tomography (CT) scan with contrast of the chest and abdomen was ordered which was significant for a large 4.3 x 4.1 x 4.5 cm complex mass in the right lobe of the liver with multiple septations. Ultrasound of the abdomen showed a heterogeneous, hypoechoic, multiseptated hepatic mass with internal vascularity, however, a neoplastic, infectious or protozoa process could not be differentiated. He was admitted to the general medicine floor, was started on vancomycin and piperacillin/tazobactam with fluid resuscitation consisting of crystalloids, and blood cultures were ordered. Shortly after admission he became tachypneic, tachycardic and hypoxic with oxygen saturations in the 50s. At that time, he was placed on high-flow oxygen and had a rebound of his oxygen saturations to the low 90s, but still remained tachypneic and tachycardic. At this time, it was determined that he would benefit from admission to the medical intensive care unit (MICU). An arterial blood gas (ABG) was obtained and was significant for a pH of 7.34, a pCO2 of 26, and a bicarbonate of 14. He was placed on bilevel positive airway pressure ventilation and was continued on his antibiotics.

The repeat CT of thorax and abdomen was again significant for a large, complex hepatic mass, but now showed areas of consolidated infiltrate with some associated atelectatic change in the posterior right lower lobe. Magnetic resonance imaging (MRI) was recommended and showed a peripherally enhancing mass in the anterior segment of the right hepatic lobe that measured 3.5 cm x 3.3 cm with areas of central septations. Blood cultures grew Klebsiella pneumonia on the second day of admission with a MIC< 1 for ceftriaxone. He was placed on ceftriaxone and the abscess was drained by interventional radiology. The gram stain and cultures of pus were negative. The patient progressed well through his hospital course and was transferred out of the MICU after three days and from the hospital after 11 days. He was seen by infectious disease two months after discharge and a repeat CT of the abdomen showed interval improvement of the abscess.

Once thought to be isolated to Southeast Asia, pyogenic liver abscess (PLA) caused by Klebsiella pneumonia (K.pneumoniae), a potentially life-threatening cause of intra-abdominal infections in septic patients, is now seen across the World [ 2 ]. K.pneumoniae is now recognized as the most common isolate in both Asia and the USA and is seen in greater than 60% of monomicrobial and polymicrobial PLA infections [ 3 - 4 ]. The gram-negative K.pneumoniae is a well-known pathogen that is identified in multiple disease processes; however, what makes K.pneumoniae PLA unique is the patient population afflicted, its virulence and diagnostic features.

The most common presenting symptoms of K.pneumoniae PLA are fever, nausea, vomiting, and abdominal pain over the right upper quadrant. An elevated white blood cell count is almost universally seen. Asian ethnicity, recent antibiotic use, diabetes mellitus and impaired fasting blood glucose are the most important predisposing risk factors for developing K.pneumoniae PLA. Although males and those from Southeast Asia are over represented, PLA has been seen in all sexes and ethnicities. Diabetics tend to have monomicrobial abscess and disease process is typically more invasive with metastases to other organs, is often present and can lead to overwhelming sepsis. Septic endophthalmitis is strongly associated with the more virulent strains and diabetics [ 5 ]. Respiratory symptoms are often seen in invasive disease as the lungs are a common target for metastatic spread. The presence of meningitis, visual symptoms, dyspnea, cough, chest pain, large abscess size, all portend a worse prognosis and increased mortality [ 6 ].

Impaired neutrophil phagocytosis is what allows K.pneunoniae PLA to form in predisposed individuals. K1 K.pneumonia is the most commonly identified serotype seen in diabetics with invasive disease [ 5 ]. A novel gene, mapA, encoding for an outer membrane protein is commonly identified in invasive cases. Although, its exact virulence mechanism is not completely understood, when mapA is lost K.pneumoniae was susceptible to phagocytosis and became avirulent in mice. Because mapA is ubiquitous in virulent cases it could one day possibly be used as a laboratory marker for early identification in cases of suspected PLA. Hypermucoviscosity also plays a role in virulence in those with invasive disease, however, the exact mechanism of how hypermucoviscosity aides in virulence remain elusive.

Typical findings of K.pneumoniae PLA on abdominal computed tomography with contrast are a single, thin walled, multiseptated, solid masses with necrotic centers [ 7 - 8 ]. A predominately solid appearance is seen under ultrasound and aspiration often yields little pus with abundant necrotic material [ 9 ]. Monotherapy with an extended spectrum penicillins, such as piperacillin-tazobactam, or the third generation cephalosporin ceftriaxone in combination with metronidazole are first line therapies [ 10 ]. If unavailable, carbapenems or fluoroquinolones in conjunction with metronidazole can be used as second line therapy. Antibiotic resistance is more common in nosocomial infections; thankfully, however extended spectrum beta-lactamase strains (ESBL) are rarely seen. As with any abscess, prompt drainage with or without drain placement should be done early in the disease course.

Conclusions

PLA should be part of the differential diagnosis of liver mass in the setting of sepsis, as K.pneumoniae is the most common isolate from both monomicrobial and polymicrobial PLA. Diabetes mellitus is the single most important risk factor for contracting K.pneumoniae PLA. Imaging of K.pneumoniae PLA often shows a solid, multiloculated mass. K.pneumoniae PLA, in particular, has a propensity to metastasize to other organs and cause systemic symptoms, and prompt drainage along with antibiotics drastically decrease morbidity and mortality.  

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained by all participants in this study

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Laparoscopic drainage of liver abscess: case report and literature review

• PMID: 23837960
• PMCID: PMC3915587
• DOI: 10.11138/gchir/2013.34.5.180

Aim: To evaluate the safety and efficacy of the minimally invasive surgical approach (laparoscopic drainage) of liver abscesses in selected cases.

Case report: Male, 58 years old, from a rural area, presented with epigastric abdominal pain, fever, weight loss, loss of appetite, a palpable mass in the epigastrium and neutrophilic leukocytosis. CT revealed a complex multiloculated liver abscess in segments 2-3. Systemic antibiotic therapy alone was ineffective; percutaneous drainage was excluded due to the characteristics of the lesion.

Result: Given the complexity of the lesion, a laparoscopic approach was chosen involving complete drainage of the abscess, debridement and irrigation; the cavity was unroofed using electrocautery and samples were obtained for bacterial culture and drug testing. Two drains were left in the cavity for seven days. No complications were observed.

Discussion: In accordance with the scientific literature, after thorough imaging we performed laparoscopic drainage of a large, complex liver abscess as a safe, effective alternative to open surgery when antibiotic therapy alone failed and percutaneous drainage was uncertain.

Conclusion: Not all liver abscesses can be treated with antibiotic therapy or percutaneous drainage. Laparoscopic drainage in association with systemic antibiotic therapy is a safe and effective minimally invasive approach that should be considered in selected patients.

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Liver abscess secondary to fishbone ingestion: case report and review of the literature

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Niamh Grayson, Hiba Shanti, Ameet G Patel, Liver abscess secondary to fishbone ingestion: case report and review of the literature, Journal of Surgical Case Reports , Volume 2022, Issue 2, February 2022, rjac026, https://doi.org/10.1093/jscr/rjac026

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We report a rare silent migration of a fishbone into the liver and review the relevant literature. A 56-year-old man presented with a 2-day history of dull epigastric pain and raised inflammatory markers. Computerized tomography scan revealed a 4-cm abscess in the left lobe of the liver, with a linear radio-dense foreign body within the collection. At laparoscopy the hepatogastric fistula was disconnected. The fishbone was retrieved from the liver. Gastrostomy was closed with an omental patch. The patient had an uneventful recovery. Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration were reported with over two-thirds presenting with a left-lobe abscess. There was marked variability in the management of liver abscess in the setting of fishbone migration-summarized in table. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and diminishes recurrence, whilst having a low-risk profile.

Foreign body ingestion is a common occurrence, majority of these pass without complications [ 1 ]. An estimated 1% of ingested foreign bodies result in gastrointestinal perforation, these are often sharp objects, such as accidentally ingested fishbones [ 2 ]. The sites of perforation vary, with the rectosigmoid or ileocolic being the most common [ 3 ].

We report a rare case of fishbone migration resulting in liver abscess and review of the literature. This was originally described in 1898 by Lambert [ 4 ].

A 56-year-old man presented with a 2-day history of epigastric pain, leucocytosis and raised C Reactive Protein (CRP). A computed tomography (CT) scan revealed evidence of a 4.2 × 2.5 cm abscess in the left lobe of the liver (Segment III), with a linear radio-dense foreign body seen within the collection ( Fig. 1 ). There was fat stranding around the pylorus. The patient was treated with antibiotics in his local hospital and a trial of aspiration revealed purulent fluid. An oesphagoduodenoscopy (OGD) was normal with no evidence of foreign body or inflammation in the stomach.

CT scan showing left lobe liver abscess with fishbone.

Review of literature reported cases of enterohepatic fishbone migration

The patient was transferred to our Hepatopancreaticobiliary (HPB) unit. On arrival, he was clinically well and asymptomatic. A repeat CT scan showed a persistent collection in the liver. On further enquiry, the patient revealed that a few weeks earlier as he had a transient episode of choking and discomfort whilst eating fish.

On laparoscopy, the left lateral segment of the liver was adherent to the gastric antrum ( Fig. 2 ). Adhesions between the liver and stomach were divided with blunt and sharp dissection. The fishbone was pulled out of the liver intact and extracted through the port. The abscess was opened, drained and washed. A sealed fistulous tract was identified at the antrum; this was repaired with an omental patch. The patient had an uneventful recovery and was discharged the following day.

Fishbone extraction from the liver.

Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration have been reported in the English literature ( Table 1 ). Most common symptoms included: anorexia, epigastric pain and fever. The lack of history of ingestion of a fishbone often leads to a diagnostic dilemma. CT scan was diagnostic in 47 that had axial imaging, three fishbones were found intra-operatively and two on autopsy. Over two-thirds of reported cases presented with a left lobe abscess, this is attributable to the anatomical proximity of the stomach.

There was marked variability in the management of liver abscess in the setting of fishbone migration. A variety of approaches including laparotomy, laparoscopy, CT guidance and liver resection were utilized to remove the fishbones. Percutaneous drainage usually results in the resolution of liver abscess, but recurrence is likely. Nine patients had the fishbone left in situ , one patient ultimately required a laparotomy for fishbone removal [ 5 ]. There were two mortalities in these patients with the fishbone left in situ (2/7, 29%), these were secondary to overwhelming sepsis, and the fishbones were discovered at autopsy [ 6 , 7 ].

Left lobe liver abscess should raise the suspicion of a foreign body. Antibiotic treatment and drainage are effective in the short term. The retained foreign body acts as a nidus for recurrent infection and requires removal to prevent recurrence and mortality.

Previous presentation: Poster presentation in UGI conference 2021.

None declared.

Kings College London (JISC affiliated).

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• inflammatory markers
• computed tomography
• epigastric pain
• pathologic fistula
• gastrostomy
• hepatic abscess
• foreign bodies
• laparoscopy
• radio communications

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Liver abscess secondary to fishbone ingestion: case report and review of the literature

Niamh grayson, hiba shanti, ameet g patel.

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Correspondence address. King’s College Hospital, Denmark Hill, London SE5 9RS, UK. Tel: +44-7740-705060; Email: [email protected]

Received 2021 Dec 2; Accepted 2022 Jan 15; Collection date 2022 Feb.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

We report a rare silent migration of a fishbone into the liver and review the relevant literature. A 56-year-old man presented with a 2-day history of dull epigastric pain and raised inflammatory markers. Computerized tomography scan revealed a 4-cm abscess in the left lobe of the liver, with a linear radio-dense foreign body within the collection. At laparoscopy the hepatogastric fistula was disconnected. The fishbone was retrieved from the liver. Gastrostomy was closed with an omental patch. The patient had an uneventful recovery. Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration were reported with over two-thirds presenting with a left-lobe abscess. There was marked variability in the management of liver abscess in the setting of fishbone migration-summarized in table. We believe that laparoscopic drainage of the abscess and extraction of the foreign body offer control of the source of sepsis and diminishes recurrence, whilst having a low-risk profile.

INTRODUCTION

Foreign body ingestion is a common occurrence, majority of these pass without complications [ 1 ]. An estimated 1% of ingested foreign bodies result in gastrointestinal perforation, these are often sharp objects, such as accidentally ingested fishbones [ 2 ]. The sites of perforation vary, with the rectosigmoid or ileocolic being the most common [ 3 ].

We report a rare case of fishbone migration resulting in liver abscess and review of the literature. This was originally described in 1898 by Lambert [ 4 ].

CASE PRESENTATION

A 56-year-old man presented with a 2-day history of epigastric pain, leucocytosis and raised C Reactive Protein (CRP). A computed tomography (CT) scan revealed evidence of a 4.2 × 2.5 cm abscess in the left lobe of the liver (Segment III), with a linear radio-dense foreign body seen within the collection ( Fig. 1 ). There was fat stranding around the pylorus. The patient was treated with antibiotics in his local hospital and a trial of aspiration revealed purulent fluid. An oesphagoduodenoscopy (OGD) was normal with no evidence of foreign body or inflammation in the stomach.

CT scan showing left lobe liver abscess with fishbone.

The patient was transferred to our Hepatopancreaticobiliary (HPB) unit. On arrival, he was clinically well and asymptomatic. A repeat CT scan showed a persistent collection in the liver. On further enquiry, the patient revealed that a few weeks earlier as he had a transient episode of choking and discomfort whilst eating fish.

On laparoscopy, the left lateral segment of the liver was adherent to the gastric antrum ( Fig. 2 ). Adhesions between the liver and stomach were divided with blunt and sharp dissection. The fishbone was pulled out of the liver intact and extracted through the port. The abscess was opened, drained and washed. A sealed fistulous tract was identified at the antrum; this was repaired with an omental patch. The patient had an uneventful recovery and was discharged the following day.

Fishbone extraction from the liver.

Fifty-two cases of liver abscess secondary to enterohepatic fishbone migration have been reported in the English literature ( Table 1 ). Most common symptoms included: anorexia, epigastric pain and fever. The lack of history of ingestion of a fishbone often leads to a diagnostic dilemma. CT scan was diagnostic in 47 that had axial imaging, three fishbones were found intra-operatively and two on autopsy. Over two-thirds of reported cases presented with a left lobe abscess, this is attributable to the anatomical proximity of the stomach.

Review of literature reported cases of enterohepatic fishbone migration

There was marked variability in the management of liver abscess in the setting of fishbone migration. A variety of approaches including laparotomy, laparoscopy, CT guidance and liver resection were utilized to remove the fishbones. Percutaneous drainage usually results in the resolution of liver abscess, but recurrence is likely. Nine patients had the fishbone left in situ , one patient ultimately required a laparotomy for fishbone removal [ 5 ]. There were two mortalities in these patients with the fishbone left in situ (2/7, 29%), these were secondary to overwhelming sepsis, and the fishbones were discovered at autopsy [ 6 , 7 ].

LEARNING POINTS/TAKE-HOME MESSAGES

Left lobe liver abscess should raise the suspicion of a foreign body. Antibiotic treatment and drainage are effective in the short term. The retained foreign body acts as a nidus for recurrent infection and requires removal to prevent recurrence and mortality.

Previous presentation: Poster presentation in UGI conference 2021.

CONFLICT OF INTEREST STATEMENT

None declared.

Kings College London (JISC affiliated).

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Lactococcus lactis endocarditis and liver abscess in an immunocompetent patient: a case report and review of the literature

• Wahib Lahlou   ORCID: orcid.org/0000-0003-4618-8865 1   na1 ,
• Abderrahim Bourial   ORCID: orcid.org/0000-0003-3801-1162 4   na1 ,
• Taib Maaouni 1 ,
• Ahmed Bensaad   ORCID: orcid.org/0000-0001-6718-1588 2 ,
• Ilham Bensahi   ORCID: orcid.org/0000-0003-3540-5043 3 ,
• Mohamed Sabry 3 &
• Mohamed Miguil 1  

Journal of Medical Case Reports volume  17 , Article number:  115 ( 2023 ) Cite this article

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Metrics details

Over the last two decades, several cases of infections caused by Lactococcus lactis have been reported. This Gram-positive coccus is considered non-pathogenic for humans. However, in some rare cases, it can cause serious infections such as endocarditis, peritonitis, and intra-abdominal infections.

Case presentation

A 56-year-old Moroccan patient was admitted to the hospital because of diffuse abdominal pain and fever. The patient had no past medical history. Five days before his admission, he developed abdominal pain in the right lower quadrant along with chills and feverish sensations. Investigations showed a liver abscess, which was drained, and the microbiological study of the pus revealed Lactococcus lactis subsp. cremoris . Three days after admission, control computed tomography objectified splenic infarctions. Cardiac explorations were performed and showed a floating vegetation on the ventricle side of the aortic valve. We retained the diagnosis of infectious endocarditis according to the modified Duke criteria. The patient was declared afebrile on day 5 and the evolution was clinically and biologically favorable. Lactococcus lactis subsp. cremoris , formerly known as Streptococcus cremoris , is a rare cause of human infections. The first case of Lactococcus lactis cremoris endocarditis was reported in 1955. This organism includes three subspecies: lactis , cremoris , and hordniae . A MEDLINE and Scopus search showed only 13 cases of infectious endocarditis due to Lactococcus lactis , with subsp. cremoris identified in four of the cases.

Conclusions

To our knowledge, this is the first case report of the co-occurrence of Lactococcus lactis endocarditis and liver abscess. Despite its reported low virulence and good response to antibiotic treatment, Lactococcus lactis endocarditis must be considered a serious disease. It is imperative for a clinician to suspect this microorganism of causing endocarditis when they notice signs of infectious endocarditis in a patient with a history of consumption of unpasteurized dairy products or contact with farm animals. The finding of a liver abscess should lead to an investigation of endocarditis, even in previously healthy patients without obvious clinical signs of endocarditis.

Peer Review reports

Over the last two decades, several cases of infections caused by Lactococcus lactis have been reported. Widely used for the production of fermented products, this Gram-positive coccus is considered nonpathogenic for humans [ 1 ]. However, in some rare cases involving both immunocompetent and immunocompromised patients [ 2 ], it can cause serious infections such as endocarditis, peritonitis, and intra-abdominal infections[ 3 ].

In this article, we report a rare case of an immunocompetent 56-year-old male with a history of raw milk consumption who presented with a Lactococcus -associated liver abscess and endocarditis.

To our knowledge, this is the first reported case in the literature (on the basis of the MEDLINE and Scopus databases) of a concurrent discovery of the association of a liver abscess and an endocarditis caused by Lactococcus lactis .

A 56-year-old Moroccan patient was admitted to the hospital for diffuse abdominal pain and fever. The patient was a bricklayer, reported no past medical history and no alcohol consumption, but was an active smoker. Five days before admission, the patient developed abdominal pain in the right lower quadrant along with chills and feverish sensations. Initially, the patient received symptomatic treatment with phloroglucinol (80 mg three times a day) and showed no improvement. In contrast, his abdominal pain increased and became diffuse.

On admission, his temperature was 39 °C, his pulse was 126 beats per minute, his blood pressure was 140/76 mmHg, his respiratory rate was 15 breaths per minute, his oxygen saturation was 94% in ambient air, and his Glasgow Coma Scale (GCS) score was 15/15.

Physical examination showed diffuse abdominal tenderness on palpation and decreased vesicular murmurs in the right chest. There were no valvular murmurs, and no mucocutaneous lesions of infectious endocarditis such as Janeway lesions, Osler nodes, or splinter hemorrhages under the fingernails. The rest of the examination was normal.

The biological assessment, carried out in the emergency department, showed leucocytosis with neutrophilia, hypereosinophilia, and monocytosis (white blood cell count of 14,960 per mm 3 , neutrophil count of 9930 per mm 3 , eosinophil count of 2570 per mm 3 , and monocyte count of 1210 per mm 3 ). The plasma C-reactive protein level was 419.37 mg/l, and the procalcitonin level was 4.660 ng/ml. The liver function tests were elevated, with an aspartate aminotransferase level of 139.1 UI/L and an alanine aminotransferase level of 279 UI/L. Kidney function was normal with a creatinine level of 8.7 mg/L and urea level of 0.52 g/L. The electrocardiogram performed on admission was normal.

Thoraco-abdomino-pelvic computed tomography (CT) showed right basal pneumonia, mild bilateral pleural effusion, low abundance perihepatic fluid effusion, and an abscess in segment VII of the liver measuring 87 × 70 mm. (Figs . 1 and 2 ).

Abdominal computed tomography revealed a multiloculated hypodensity in segment VII, suggesting a liver abscess (white arrowhead)

Thoracic computed tomography revealed a mild predominantly right bilateral pleural effusion (white arrowheads)

Surgical drainage was recommended and performed under general anesthesia. The exploration showed a fissured abscess through which we noted the exit of pus. It was drained by a Salem sump drain with pus sampling for cytobacteriological study. The pus was cultured and grew Lactococcus lactis subsp. cremoris . During hospitalization, repeated aerobic and anaerobic blood cultures were taken and cultured, all of which were negative.

The postoperative follow-up was simple. The patient was treated empirically with intravenous antibiotics: metronidazole (500 mg three times daily), imipenem (500 mg four times daily), and amikacin (1 g once a day). The amikacin was stopped at day 5. Three days after admission, we carried out a control CT that objectified a more organized aspect of the pre-suppurative phase liver abscesses and areas of splenic infarction (Fig.  3 ). Transthoracic echocardiography was performed and was normal with no evidence of vegetations, no valvular or paravalvular regurgitation, and no aortic abscess or pericardial effusion. A decision to carry out transesophageal echocardiography was made, where a floating vegetation on the ventricle side of the aortic valve measuring 8 × 5 mm was observed and there were no imaging of an abscess or Valsalva aneurysm (Fig.  4 ).

Control abdominal computed tomography revealed areas of splenic infarction (white arrowheads)

Transesophageal echocardiography showed a floating and vibratile vegetation measuring 8 × 5 mm on the ventricular side of the aortic valve

Investigations of immune function demonstrated that he was HIV negative.

The patient was declared afebrile on day 5. The drainage catheter was removed on day 6 when the drained fluid was minimal.

As part of the endocarditis extension assessment, the patient underwent a cerebral CT that showed no abnormalities.

In total, the patient was treated with imipenem for 4 weeks and metronidazole was also continued for 3 weeks to cover other potential anaerobic germs.

The outcome was clinically and biologically favorable with negativation of the infection’s biomarkers (procalcitonin, C-reactive protein, and total white blood cell count) without occurrence of AV-type electrical complications.

On follow-up in the outpatient clinic after 2 months, the patient was well and asymptomatic with normalized biochemistry and almost complete regression of the liver abscess and splenic infarctions on CT (Fig.  5 ). Moreover, on the control transesophageal echocardiography, we remarked that the vegetation had decreased in size without the occurrence of any complications.

Control computed tomography on follow-up after 2 months showed almost complete regression of the liver abscess and splenic infarctions

The patient was reviewed in consultation after 8 months, and was totally asymptomatic.

Discussion and conclusions

To our knowledge, and up to date in the current literature, this is the first described case of concurrent discovery of a liver abscess associated with endocarditis caused by Lactococcus lactis.

Lactococcus lactis is a Gram-positive bacterium used for the production of fermented dairy products, particularly cheddar cheese. Five species of the genus Lactococcus have been described: L. lactis , L. garvieae , L. piscium , L. plantarum , and L. raffinolactis [ 4 , 5 ].

L. lactis actually includes three subspecies: L. lactis  subsp.  lactis , L. lactis  subsp.  cremoris , and L. lactis  subsp.  hordniae [ 4 , 5 ].

Most bacteria employed in food preparation are killed during digestion (following ingestion), but it has been established that Lactococcus remains viable after transit through the gastrointestinal tract, which is considered to be the mechanism of Lactococcus lactis infection in humans, especially when there is a loss of intestinal wall integrity[ 2 , 6 ]. This may justify colonoscopy as part of the investigation.

In some cases (similar to ours), the ingestion of unpasteurized milk, sour cream, or yogurt was recognized. However, in other cases, there was no history of ingestion of unpasteurized dairy products. Owing to the rarity of Lactococcus lactis infection, the source of this infection has not been well demonstrated. The hypotheses regarding the source of infection include the ingestion of unpasteurized dairy products or direct intraluminal inoculation from contaminated hands[ 7 ].

Lactococcus lactis has low virulence and is considered nonpathogenic. However, it has recently been considered an opportunistic pathogen microbe. A pathophysiological mechanism has been described to explain the virulence of this microorganism in the genesis of infectious endocarditis. Indeed, a study carried out in 2016 showed that Lactococcus lactis expresses the glycoprotein Cnm, which promotes its adhesion to type I collagen and to cardiac tissues (in particular the tissues of the aortic valve) [ 8 ].

We retained the diagnosis of infectious endocarditis for our patient according to the modified Duke criteria. [ 9 , 10 ]. Repeated blood cultures taken during hospitalization did not grow any specific pathogen that could probably be attributed to previous antibiotic treatment. According to the literature, the rate of culture-negative endocarditis varies from 2.1% to 35% [ 11 ]. In our case, the vegetation was not visualized on transthoracic echocardiography although it was a quite voluminous aortic localization and this imaging had good sensitivity for the exploration of the aortic sigmoids [ 12 ]. This highlights the fact that it is necessary to perform transesophageal echocardiography when endocarditis is a clinical possibility.

Infectious endocarditis due to Lactococcus lactis is very rare, and a MEDLINE and Scopus search (Table 1 ) identified only 13 cases of infectious endocarditis due to Lactococcus lactis , with the subsp. cremoris identified in four of the cases. In these four cases, including ours, the affected valve was the aortic valve. However, in other cases, endocarditis affected the mitral valve, which is the most commonly involved valve, followed by the tricuspid valve. The outcomes of the few reported cases were good: only two patients died (including one infant diagnosed postmortem and one adult whose course was complicated by bilateral uncal herniation due to multiple intracerebral hemorrhages). This underlines the good prognosis of Lactococcus lactis endocarditis.

Liver abscess is the second most common localization of Lactococcus lactis infections after endocarditis. Reviewing the MEDLINE and Scopus databases, we found nine cases of hepatic abscess due to Lactococcus lactis : most frequently Lactococcus lactis subsp. cremoris in four cases, Lactococcus lactis subsp. lactis in one case, and no available data regarding the subspecies in four cases [ 1 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 ].

We remark that six out of the nine cases did not accomplish proper cardiac exploration (transthoracic echocardiography nor transesophageal echocardiography). Note that in the other three cases, no available data were found.

Our case is the first liver abscess described in the literature with a proper cardiac exploration that found a co-occurrence of infectious endocarditis. We therefore wonder if this association is underdiagnosed as opposed to what is described, and find it logical to recommend systematic ultrasound cardiac exploration in the case of any Lactococcus lactis hepatic abscess.

A liver abscess formation is explained by its anatomical and physiological singularity. The liver receives blood from the systemic and portal circulations, from which the infected bloodstream can carry the bacterium, and the infection spread in this case was considered hematogenous. The usual pathophysiology behind liver abscess formation can be assumed as bowel content leakage and peritonitis rout. The bacteria can travel through the portal vein to reach the liver and reside there. Less frequently, the infection can originate from the biliary system[ 32 ].

Table 2 presents all available multiple localizations of Lactococcus lactis infections. Nine cases have been described in the literature, from which we find four cases of endocarditis and five liver abscesses as the starting point of the systemic infection.

Six out of the nine cases indicated Lactococcus lactis subsp. cremoris , knowing that the other three cases lacked information and did not specify the subspecies of Lactococcus lactis . Therefore, the cremoris subspecies is more likely to be spread systemically and carried to multiple organs, regardless of the infection starting point, as this hypothesis is consistent with our case.

We found that consumption of unpasteurized milk or cheese was present in three out of the nine cases. It is plausible that the inoculation of the microorganism occurred through an orofecal mechanism. Although Lactococcus inoculation is more prone to be accomplished through the digestive duct, endocarditis and liver abscess seem to be equally frequent as a triggering systemic infection site.

Underlying conditions were documented in eight out of the nine cases identified in the MEDLINE and Scopus database articles and only one patient had an immunocompromised state related to his condition (cholangiocarcinoma). On the basis of the literature, immunodeficiency or immunocompromisation may be a predisposing factor linked with Lactococcus lactis infection with liver abscess localization[ 3 ].

The most frequent localizations that lead to multiple localizations infection other than the heart and the hepatobiliary tract are the pleura, lungs, brain, retroperitoneal organs, bones, and so on, as they are often the starting infection sites. [ 3 ]

The majority of hepatobiliary-starting Lactococcus infection cases did not benefit from proper cardiac exploration. We found that cases 2, 6, and 9 had positive blood culture with a non-specific endocarditis germ (minor modified Duke criteria) with some other minor criterion. On the basis of the modified Duke criteria, these cases had a score of 3, compatible with a possible endocarditis diagnosis. We therefore propose a systematic ultrasound cardiac exploration in front of any Lactococcus lactis hepatic abscess or multiple localization Lactococcus lactis infection, looking for an endocarditis echocardiographic finding.

Pleural effusion, especially in the right chest, was frequently linked with Lactococcus lactis infections, particularly when the infection started with liver abscesses. The possible mechanism of propagation might be through the bloodstream, as well as through a locoregional process, considering the anatomical links.

The outcome was favorable in the majority of cases, suggesting that early treatment may be a major prognostic factor in this kind of infection.

One of the interesting findings in this case was the elevated monocyte count. This patient presented concomitant monocytosis within the endocarditis episode. It is known that monocytosis can be caused by a wide variety of neoplastic and nonneoplastic conditions [ 33 ]. The various causes of monocytosis can be divided into two broad categories: clonal or reactive, from which acute infections such as endocarditis can be an etiologic factor [ 34 ]. Infective-endocarditis-related bacteria are described in the literature as activating factors of blood monocytes. Activated monocytes are believed to be important factors, participating in the formation of endocarditis vegetations by producing cytokines and procoagulant factors that enhance the development of the infected coagulum, formally known as vegetation [ 35 , 36 ].

Lactococcus lactis , formerly known to be a nonpathogenic microorganism, has contributed to several cases of human infections, including infectious endocarditis and liver abscesses. It is essential for a clinician to suspect this microorganism of causing endocarditis when they notice signs of infectious endocarditis in a patient with a history of consumption of unpasteurized dairy products or contact with farm animals. This case suggests the hypothesis that the finding of a liver abscess may require an investigation of endocarditis even in previously healthy patients without obvious clinical signs of endocarditis.

Here, we report here the fourteenth case of endocarditis caused by Lactococcus lactis described in the literature and the first case report of the co-occurrence of Lactococcus lactis endocarditis and liver abscess.

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The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Computed tomography

Human immunodeficiency virus

• Lactococcus lactis

Lactococcus garvieae

Lactococcus piscium

Lactococcus plantarum

Lactococcus rafinolactis

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WL and AB contributed equally to the work

Authors and Affiliations

Department of Polyvalent Resuscitation Unit, Cheikh Khalifa International University Hospital, Mohammed VI University of Sciences and Health, Casablanca, Morocco

Wahib Lahlou, Taib Maaouni & Mohamed Miguil

Department of Visceral Surgery, Cheikh Khalifa International University Hospital, Mohammed VI University of Sciences and Health, Casablanca, Morocco

Ahmed Bensaad

Department of Cardiology, Cheikh Khalifa International University Hospital, Mohammed VI University of Sciences and Health, Casablanca, Morocco

Ilham Bensahi & Mohamed Sabry

Cheikh Khalifa International University Hospital, Mohammed VI University of Sciences and Health, Casablanca, Morocco

Abderrahim Bourial

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WL, TM, MM, and ABe took part in taking care of the patient. IB and MS performed the echocardiography and assisted in the drafting of the manuscript. ABe took part in researching the bibliography and assisted in the drafting of the manuscript. WL and ABo took part in researching the bibliography and writing the article. TM and MM revised the final manuscript. All authors read and approved the final manuscript.

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Lahlou, W., Bourial, A., Maaouni, T. et al. Lactococcus lactis endocarditis and liver abscess in an immunocompetent patient: a case report and review of the literature. J Med Case Reports 17 , 115 (2023). https://doi.org/10.1186/s13256-022-03676-1

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Received : 14 June 2022

Accepted : 08 November 2022

Published : 31 March 2023

DOI : https://doi.org/10.1186/s13256-022-03676-1

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