Answer to case of the month #162. Emphysematous infection of the liver parenchyma

Diagnostic and Management of Emphysematous Hepatitis with Emphasis on Biopathology

Emphysematous hepatitis is a rare infectious disease, which corresponds to the presence of gas in the liver, without collection and after exclusion of vascular origin. This entity belongs to the group of emphysematous infections, whose physiopathology seems to be linked to the presence of unbalanced diabetes and to bacterial fermentation, leading to the production of gas within the liver parenchyma. Very few cases of emphysematous hepatitis have been described in the literature, and most of them had a rapidly fatal course. In this manuscript, we report the case of a 59-year-old man with emphysematous hepatitis due to wild-type Klebsiella pneumoniae that was successfully managed by surgery, and we perform a review of the literature to describe the clinical and biopathological aspects of this rare hepatic disease. Our manuscript underlines the need to perform biological and histopathological sampling to better understand the pathophysiology of this rare entity. The causes and mechanisms of emphysematous hepatitis, which seem to be multiple, lead us to believe that it is a syndrome rather than a simple infectious disease.

First successful treatment of Clostridium perfringens-associated emphysematous hepatitis: a case report

Emphysematous diseases of the abdomen are rare with an often inconspicuous presentation of symptoms and rapid lethal outcome if untreated. We report the first successfully treated case of Clostridium perfringens-associated emphysematous hepatitis. In the emergency room, a 79-year-old man presented with shortness of breath and deteriorated general condition since the morning of admission. Initial CT scans showed a small but rapidly expanding gas collection in liver segment 6. Emergency surgery with atypical liver resection was performed immediately. With early resection and prolonged administration of antibiotics in the presence of sepsis, the patient recovered successfully and was discharged 37 days after admission. As in our case, prompt diagnosis with early surgical treatment is crucial for the management of emphysematous hepatitis.

Medical management of feline emphysematous hepatitis-A case report

Case report summary: A 9-year-old male castrated domestic shorthair feline was presented to the emergency department with a chief complaint of constipation of 3-day duration, decreased urination of 1-day duration, vomiting, and hind limb weakness. Physical examination abnormalities included hypothermia, dehydration, and generalized paresis with inability to stand for a prolonged period of time. Abdominal ultrasonography showed pinpoint hyperechoic foci throughout the hepatic parenchyma, small gas foci circulating within the portal vasculature consistent with emphysematous hepatitis, and mild volume of ascites. Cytology of the ascites was consistent with inflammatory effusion. Hepatic cytology was consistent with mixed inflammation/hepatitis with no apparent cause for inflammation noted. Urine culture yielded a negative result. Surgical liver biopsy and culture were declined by the patient's family. Ultrasound changes were presumed to be most likely secondary to an ascending infection.

Emphysematous hepatitis with successful treatments: A rare case report

RATIONALE

Emphysematous hepatitis (EH) is a rare and fulminant gas-forming liver infection. Only 3 patients were successfully treated. Diabetes mellitus and a history of digestive system cancer may predispose individuals to EH. Computed tomography (CT) findings support the diagnosis of EH and monitor progress.

PATIENT CONCERNS

A 48-year-old man with diabetes presented with nausea, vomiting (gastric contents) and diarrhea. Laboratory test results revealed elevated levels of inflammatory indicators and abnormal liver function. CT showed a large-scale air collection with some remaining parenchymal debris in the left lobe of the liver. Remarkably, no fluid was observed inside the lesion.

DIAGNOSE

The abdominal CT features and laboratory examination results rationalized the diagnosis of EH.

INTERVENTIONS AND OUTCOMES

The patient finally recovered from this severe disease through a series of effective treatments, including strict glucose control, sensitive antibiotic therapy, and subsequent percutaneous drainage.

LESSONS

EH generally deteriorates rapidly and eventually leads to death. This case will raise awareness of the rare and severe disease, strengthen diagnostic capacities, and provide advice to treat it.

Step-up approach in emphysematous hepatitis: A case report

BACKGROUND

Emphysematous hepatitis (EH) is a rare, rapidly progressive fulminant gas-forming infection of the liver parenchyma. It is often fatal and mostly affects diabetes patients.

CASE SUMMARY

We report a case of EH successfully managed by a step-up approach consisting of aggressive hemodynamic support, intravenous antibiotics, and percutaneous drainage, ultimately followed by laparoscopic deroofing. Of 11 documented cases worldwide, only 1 of the patients survived, treated by urgent laparotomy and surgical debridement.

CONCLUSION

EH is a life-threatening infection. Its high mortality rate makes timely diagnosis essential, in order to navigate treatment accordingly.

13-Hour progression of emphysematous hepatitis as depicted on repeat computerized tomography

Emphysematous hepatitis is a rare, rapidly progressive and often fatal condition, which occurs predominantly in patients with uncontrolled diabetes mellitus. It results in the replacement of liver parenchyma by a collection of gas. Emphysematous infections of other abdominal and pelvic organs have long been established, but relatively little is known about the equivalent emphysematous infection of the liver with very few examples in the published literature. A review of the literature shows variability regarding timing of presentation and implicated organisms. To date, computerized tomography imaging has been purported to be diagnostic and vital to early management, as it clearly shows the characteristic appearance of air bubbles within the liver parenchyma. We report a case with inconclusive initial radiographic findings.

Gas-Forming Liver Abscess versus Emphysematous Hepatitis: A Radiologic Diagnostic Dilemma-A Case Report and Review of the Literature

A 38-year-old diabetic woman, with history of cholecystectomy and ventral hernia repair, was hospitalized due to sudden-onset abdominal pain and fever. Computed tomography revealed a mixed collection containing necrotic debris and emphysematous change in the left lobe of the liver mainly in segments II and III. These radiological findings suggested emphysematous hepatitis (EH). The patient's condition deteriorated rapidly, and she was rushed to the operating room for urgent exploratory laparotomy where debridement was performed. Intraoperatively the patient was found to have an abscess with incomplete capsule concurrent with hepatic necrosis suggesting the co-occurrence of abscess and EH. The patient survived and was discharged after 13 days. Relevant literature was reviewed, and to the best of our knowledge, EH is an extremely rare entity with limited data regarding its pathogenesis, causative organisms, and management. EH is a rapidly invasive disease process that can be fatal if appropriate therapeutic intervention is delayed. Initial presentations are usually subtle, thus high clinical and radiological suspicion is required for early diagnosis and management to decrease associated mortality and morbidity. We hence report the first successfully treated case of EH with review of the literature.