Case of the Month #162

The patient was febrile (39.1 0C), but other vital signs were normal. Icterus was the prominent feature on physical examination. Initial laboratory evaluation revealed marked leucocytosis (35.0 cells/109 L [reference range, 4.8-10.8 cells/109 L]), abnormal liver function tests (total bilirubin 140 pmol/L [reference range, 7-23 µ???/L], alanine transaminase 475 U/L [reference range, 11-51 UVL], and aspartate transaminase 496 U/L [reference range, 13-39 U/L]), and mildly prolonged prothrombin time (international normalized ratio 1.2). Chest x-ray (Figure 1) and contrastenhanced computed tomography (Figure 2) were then performed. The patient was febrile (39.1°C), but other vital signs were normal. Icterus was the prominent feature on physical examination. Initial laboratory evaluation revealed marked leucocytosis (35.0 cells/109 L [reference range, 4.8-10.8 cells/109 L]), abnormal liver function tests (total bilirubin 140 µ???/L [reference range, 7-23 µ???/L], alanine transaminase 475 UVL [reference range, 11-51 U/L], and aspartate transaminase 496 U/L [reference range, 13-39 U/ L]), and mildly prolonged prothrombin time (international normalized ratio 1.2). Because no fluid was present in the collection, it was thought that percutaneous drainage would be futile. The remaining healthy liver parenchyma was judged too small to attempt a surgical debridement. Instead, a trial of intravenous antibiotics was begun. After a few hours, the patient developed septic shock and was transferred to the intensive care unit. A follow-up noncontrast enhanced CT was ordered 12 hours after the initial examination and revealed a dramatic progression of the air-filled hepatic cavity (Figure 4). Free intraperitoneal air was also seen. The patient's neurologic and hemodynamic status deteriorated rapidly before emergent surgical debridement could be attempted. Terminal hypoglycemia was observed in the setting of this acute hepatic failure (measured alanine transaminase 2,600 U/L, and aspartate transaminase 3,740 U/L). The patient died 36 hours after his admission to the emergency department. Blood culture grew Enterobacter cloacae and Clostridium perfringens.