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| Journal of the New Zealand Medical Association,
31-March-2006, Vol 119 No 1231
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A “fishy” cough: hepatobronchial fistula due to a
pyogenic liver abscess
Fouad Moawad, Alex Truesdell, Brian Mulhall
A hepatobronchial fistula is an anatomic communication
between the liver parenchyma and the bronchial tree. Major causes of such
fistulae include inflammatory conditions resulting from obstruction of the
biliary tract and infectious processes, such as pyogenic liver abscesses,
amoebiasis, and hydatid cysts.
We report a rare case of a patient (with a chronic,
recurrent hepatic abscess) who suffered a persistent, productive cough resulting
from a hepatobronchial fistula.
Case reportA 49-year-old white male presented to the emergency
department complaining of three days of fever, chills, shortness of breath, and
cough productive of “fishy” tasting sputum. The patient had a
history of a chronic recurrent hepatic abscess diagnosed 2 years prior, at which
time CT imaging revealed a 5.5 cm abscess localised to the medial segment of the
right lobe of the liver.
The abscess had been refractory to multiple courses of
intravenous antibiotics, ultrasound-guided percutaneous drainage, and wedge
resection. Previous intraoperative tissue samples were negative for malignancy
and cultures were negative for aerobic, anaerobic, fungal, and acid-fast
organisms. On examination, he was afebrile and his vital signs were normal. He
was coughing persistently.
Gross examination of his sputum revealed a dark expectorate.
The remainder of his physical examination was unremarkable. Laboratory
evaluation revealed a white blood cell count of 13,600 per cubic millimetre with
a predominance of neutrophils. Liver associated enzymes revealed an alkaline
phosphate level of 747 U/L.
Plain chest radiography was notable for pneumobilia and an
elevated right hemidiaphragm. CT scan demonstrated a residual 8cm septated
hepatic abscess (Figure 1) and a fistulous tract communicating with the
bronchial tree (Figure 2). A pigtail drain was placed under CT guidance and the
patient was empirically started on ceftriaxone, ciprofloxacin, and
metronidazole.
Cultures of the aspirate later grew multiple organisms to
include Clostridium
perfringens,
Klebsiella pneumoniae, and
Enterococcus faecalis. At 4-week
follow-up, the patient reported termination of symptoms and CT scan demonstrated
near-complete abscess involution. The patient was continued on the same
antibiotic regimen for 6 more weeks and was followed up with serial CT scans to
assure complete resolution of the abscess.
DiscussionPyogenic hepatic abscesses are rare and seldom communicate
with the pleural space, owing to the tough membranous barrier provided by the
diaphragm. As a result, very few cases of hepatobronchial fistula have been
reported in the literature.
Our patient presented with a hepatobronchial fistula
secondary to a recurrent pyogenic liver abscess. In several large autopsy
series, the prevalence rate for incidental hepatic abscess varied from
0.029–1.47%. The most commonly reported cause is biliary
disease—with abscess typically forming secondary to ascending cholangitis
from extrahepatic obstruction.1 Other causes include infections, such as
appendicitis, which originate in the drainage distribution of the portal vein,
leading to abscess formation via seeding or embolisation. However, in the vast
majority of cases, despite extensive investigation, the cause remains
undetermined.
Complications of hepatic abscesses typically occur secondary
to spontaneous abscess rupture or direct extension into adjacent viscera.1,2
Though uncommon, the anatomic regions most characteristically involved are the
pleural space and the lung parenchyma. In the largest case review series
published to date, Oschner et al reported a 15% incidence of pleuropulmonary
involvement secondary to pyogenic hepatic abscess.1 Resultant pulmonary
complications include pneumonia, empyema, and subphrenic abscess. Similar
syndromes are also seen with hydatid cysts and amoebic abscesses.3,4
Historically, surgical drainage of the abscess and
correction of the fistulous tract have been the mainstays of therapy.5,6
However, in recent decades, authors have reported success with CT and
ultrasound-guided catheter drainage followed by long-term intravenous
antibiotics—the technique chosen for our patient.7,8
This is an interesting case of an uncommon complication of a
hepatic abscess. Although rare, the presentation of cough with peculiar tasting
sputum in a patient with a known hepatic abscess should raise suspicion for a
hepatobronchial fistula. Based upon current literature, once the diagnosis is
established, aspiration and drainage of the fistula accompanied by prolonged
antibiotic therapy should be adequate for abscess resolution and healing of the
fistula.
Author information:
Fouad J Moawad, Resident, Department of Medicine; Alex G Truesdell,
Resident, Department of Medicine; Brian P Mulhall, Gastroenterologist,
Department of Gastroenterology; Walter Reed Army Medical Center,
Washington DC, USA
Correspondence:
Fouad J. Moawad, M.D., Department of Medicine, Walter Reed Army Medical
Center 6900 Georgia Ave., NW Washington, DC 20307, USA. Fax: +1 202 782 5183;
email: Fouad.Moawad@na.amedd.army.mil
References:
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