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- W2922253750 abstract "Acute cholangitis usually results from migration of bacteria and toxins into the biliary tract in the setting of obstruction. Escherichia coli is the most commonly isolated organism while Enterococcus faecalis (e.faecalis) is the third most common. These bacteria may enter the systemic circulation and cause septicemia with distant seeding of infection. Here we report a case of acute cholangitis complicated by persistent bacteremia, pyogenic hepatic abscesses, and infective endocarditis. A 64 year-old female with multiple comorbidities was admitted to an outside facility with symptoms suggestive of acute cholangitis of four days duration. Reported laboratory testing showed elevated liver enzymes including AST, ALT and bilirubin. Computed tomography (CT) scan was remarkable for multiple hepatic ring-enhancing lesions as well as gallbladder wall thickening and cholelithiasis. The patient was treated with antibiotics for two days and transferred to our facility for further management. On arrival, vital signs were stable and the patient had no acute symptoms. Laboratory workup was remarkable for alkaline phosphatase 588 IU/L, AST 77 IU/L, ALT 33 IU/L, bilirubin 0.8 mg/dL, and Escherichia coli and e. faecalis bacteremia. Magnetic resonance cholangiopancreatography (MRCP) confirmed CT scan findings in addition to a dilated 2 cm common bile duct and right portal vein thrombosis. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and two stones were extracted. Transesophageal echocardiography showed vegetations on the aortic valve consistent with bacterial endocarditis. The patient was started on ampicillin-sulbactam, gentamycin and heparin. Despite stable vital signs and liver enzymes, e. faecalis bacteremia persisted. Surgical intervention was necessary and the patient underwent open cholecystectomy and partial hepatectomy. Microscopic examination of the liver tissue was diagnostic of hepatic abscess (Image 1) and cultures were positive for e. faecalis with the same sensitivity profile as the blood culture isolates. The patient continued to improve post operatively with negative blood cultures and was eventually discharged home. Complications from acute cholangitis may result from local extension into the liver parenchyma, hematogenous spread to distant organs, and rarely, from both. Persistent bacteremia despite apparent clinical improvement should alert the physician to the possibility of a more complicated disease course and secondary infection.1305_A.tif Figure 1: H&E stain at 40x magnification showing fibrotic, inflamed liver parenchyma with focal necroinflammatory tissue (asterisk), consistent with abscess (A). A higher power view at 200x magnification, shows degenerating hepatocytes surrounded by hemorrhage and inflammatory cells (B)." @default.
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- W2922253750 date "2018-10-01" @default.
- W2922253750 modified "2023-09-27" @default.
- W2922253750 title "Persistent Bacteremia, Hepatic Abscesses, and Infective Endocarditis Complicating a Case of Acute Cholangitis" @default.
- W2922253750 doi "https://doi.org/10.14309/00000434-201810001-01305" @default.
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