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linics and Research in Hepatology and Gastroenterology (2012) 36, e114—e116

Available online at

www.sciencedirect.com

ASE REPORT

mphysematous hepatitis — A fatal infection iniabetic patients: Case report

dit Chauhana, Shailesh M. Prabhua,∗, Gurucharan S. Shettyb,avi S. Solankia, Alok K. Udiyaa, Anuradha Singha

Lady Hardinge Medical College, New Delhi, IndiaAll India Institute of Medical Sciences, New Delhi, India

vailable online 29 June 2012

ummary Emphysematous hepatitis is a rare fatal rapidly progressive fulminant infection ofepatic parenchyma seen in the setting of diabetes characterised by replacement of hepaticarenchyma with gas collection. There is paucity of literature with regard to pathogenesis,mplicated organisms, imaging appearance and management of this condition. We report a

ase with extensive segmental replacement of liver parenchyma with gas. The fatality of thisondition warrants awareness of this entity amongst radiologists and clinicians alike for earlyiagnosis and aggressive management.2012 Elsevier Masson SAS. All rights reserved.

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lacher et al. (2001) reported a case of 43-year-old dia-etic patient who had fever and elevated white blood cellWBC) count at presentation. On imaging, there was exten-ive replacement of the entire liver parenchyma by air. Theatient expired within 3 days of admission despite treatmentith antibiotics [1]. To the best of our review of existing lit-rature, this was the first reported case of emphysematous

epatitis in humans. Emphysematous hepatitis is a rare fatalulminant infection of hepatic parenchyma characterisedy replacement of hepatic parenchyma by gas without any

∗ Corresponding author. Room no 322, House Surgeons Block, Ladyardinge Medical College and assoc, SSK and KSC hospitals, Con-aught place, New Delhi 01, India. Tel.: +91 90 13 90 04 57,ax: +91 01 13 29 15 21 6.

E-mail address: shailesh182@gmail.com (S.M. Prabhu).

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210-7401/$ – see front matter © 2012 Elsevier Masson SAS. All rights rettp://dx.doi.org/10.1016/j.clinre.2012.05.018

bscess formation or fluid collection. We report a case ofxtensive segmental replacement of liver parenchyma withas.

ase report

77-year-old male came to the medical emergency in atate of altered consciousness and shock (80/45 mmHg).atient complained of high-grade fever and right upperbdomen pain since 6 days. Patient was a known case ofoorly controlled diabetes from past 15 yrs. Random bloodugar at presentation was 450 mg/dl. Laboratory examina-ion revealed leucocytosis of 35,000 cells/mm3 with 90%eutrophils. Blood urea was 125% mg and serum creatinine

as 4.5 mg/dl. Ultrasound examination revealed presence ofxtensive dirty shadowing in segments VI and VII of liver sug-esting air collection. Other organs were normal and thereas no free fluid in the abdomen. Since the patient was in

served.

Emphysematous hepatitis e115

Figures 1—4 Emphysematous infection of hepatic parenchyma in a 77-year-old diabetic male presenting in a state of alteredconsciousness and septic shock with a history of fever and pain right upper abdomen since 6 days. Axial non-contrast CT scan imagesabdominal window settings [1,2] and lung window settings [3,4] showing replacement of hepatic parenchyma with gas involving

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segment VI and VII of liver (white arrow). No evidence of fluid cohepatic parenchyma is normal with no features of edema and m

a state of septic shock with deranged renal function non-contrast CT scan of abdomen was performed. Non-contrastCT abdomen revealed presence of localised area of air col-lection replacing the parenchyma in the segments VI and VIIof liver (Fig. 1). There was no fluid collection or any evidenceof abscess formation. Adjacent hepatic parenchyma wasnormal with no evidence any edema. The air was not seen toextend into the portal venous or biliary system. Other organswere normal with no free fluid in the abdomen. Percuta-neous drainage was attempted with pigtail catheter, whichdrained only foul smelling gas without any fluid. Patientwas treated aggressively with broad-spectrum antibioticsand supportive therapy but expired in span of 3 days afteradmission. The decision for postmortem visceral analysiswas averted due to lack of consent.

Discussion

Emphysematous infections of abdomen and pelvis includeemphysematous cholecystitis, emphysematous gastritis,

emphysematous pancreatitis, emphysematous pyelonephri-tis, emphysematous pyelitis and emphysematous cystitis[2]. Emphysematous hepatitis is a very rare emphysema-tous infection of the liver parenchyma with few isolated

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ion or abscess formation is seen in segments involved. Adjacentffect.

ase reports. These conditions represent potentially lifehreatening infections that require aggressive medical andurgical management and are known to have preponder-nce in diabetic patients. Initial clinical manifestation ofhese infections is insidious and they progress rapidly inhe absence of any therapeutic intervention [2]. The patho-hysiology of emphysematous infections is due to mixedcid fermentation from tissue necrosis by bacteria resul-ing in formation of nitrogen (60%), hydrogen (15%), carbonioxide (5%), oxygen (5%) and the impaired transport ofhese products of catabolism from the production site3,4].

Diabetes predisposes to emphysematous infections byroviding a high level of glucose in the interstitial fluid whilessociated diabetic microangiopathy results in slow trans-ort of the produced gases. Common organisms implicated inmphysematous infections are Escherichia coli, Klebsiella,lostridium welchii and Staphlococcus aureus [2]. Klebsiellaas been grown from cultures of liver aspirates of emphy-ematous hepatitis [1]. The clinical and imaging findings ofmphysematous hepatitis are similar to those that have been

escribed for emphysematous pyelonephritis and emphy-ematous cholecystitis [2]. CT is considered as the mostensitive and specific modality to detect gas within the tis-ue [2].

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Other important causes for segmental collection of airn the liver parenchyma include pyogenic liver abscess andepatic infarction subsequent to trauma and hepatic trans-lant. Hepatic abscesses are spherical or oval collections ofus, which may be septated or clustered, encapsulated andave mass effect [5,6]. Detection of gas, which is present in9% of cases or less, provides support for a higher degree ofonfidence in the imaging diagnosis of abscess [7,8]. Smallyogenic abscesses (< 3 cm) usually resolve with antibioticherapy alone, whereas larger abscesses respond well toercutaneous catheter drainage and parenteral antibiotics9].

Hepatic infarction is a result of compromise of hep-tic arterial and portovenous blood supply to liver. Hepaticnfarctions are mainly seen in the setting of liver transplan-ation and trauma. One potentially catastrophic cause ofntrahepatic gas after liver transplantation is gas gangrenef the liver graft as a result of hepatic artery thrombosis10]. Although parenchymal gas bubbles can be found in suchases widespread parenchymal necrosis with gas replacingolid parenchyma is not seen. Our case was neither a trans-lant recipient nor had any history of abdominal trauma.

Emphysematous hepatitis is a rare fatal rapidly progres-ive fulminant infection of hepatic parenchyma seen in theetting of diabetes characterised by replacement of hep-tic parenchyma with gas collection. The diagnosis of thisondition needs to be considered in the setting of ultra-ound showing extensive dirty echogenic shadowing and CThowing replacement of hepatic parenchyma with air in thebsence of fluid collections. The fatality of this conditionarrants awareness of this entity amongst radiologists andlinicians alike for early diagnosis and aggressive manage-ent. In all the existing case reports of this entity, the

atients were poor surgical candidates including our case.ence, percutaneous drainage was attempted. The utility ofurgical debridement or partial hepatectomy remains unan-wered.

[

U. Chauhan et al.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

unding: None declared.

eferences

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[3] Schainuck LI, Fouty R, Cutler RE. Emphysematous pyelonephri-tis. A new case and review of previous observations. Am J Med1968;44(1):134—9.

[4] Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glu-cose as a mechanism of emphysematous urinary tract infection.J Urol 1991;146(1):148—51.

[5] Mathieu D, Anglade MC, Fagniez PL, Segui S, Grably D,Larde D. Dynamic CT features of hepatic abscesses. Radiology1985;154:749—52.

[6] Jeffrey RB, Tolentino CS, Chang FC, Federle MP. CT of smallpyogenic hepatic abscesses: the cluster sign. Am J Roentgenol1988;151:487—9.

[7] Halvorsen RA, Korobkin M, Foster WL, Silverman PM, ThompsonWM. The variable CT appearance of hepatic abscesses. Am JRoentgenol 1984;142(5):941—6.

[8] Rubinson HA, Isikoff MB, Hill MC. Diagnostic imaging of hep-atic abscesses: a retrospective analysis. Am J Roentgenol1980;135(4):735—45.

[9] Olivera MA, Kershenobich D. Pyogenic liver abscess. Curr Treat

Options Gastroenterol 1999;2:86—90.

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