Ketamine Uropathy: A Seed to Innumerable Hepatic Abscesses

Introduction: Ketamine is known to cause hepatotoxic effects in those with heavy recreational use. Similar to its effects on the urinary tract, ketamine typically causes dilation of the intra and extra hepatic ducts with fusiform dilation of the common bile duct suggestive of choledochal cysts. We present a rare case of hepatic abscesses as a complication of ketamine induced uropathy. Case Description/Methods: A 27-year-old Hispanic man with history of daily recreational ketamine use presents with dysuria and urinary retention admitted for sepsis. Labs notable for serum alkaline phosphatase elevation to 1564 U/L, total bilirubin elevation to 1.4 mg/dL, creatine 3.9 mg/dL, and leukocytosis to 25 mcL. Computed tomography (CT) was notable for innumerable liver lesions (Figure 1B) that were not seen two months prior (Figure 1A), and bilateral hydronephrosis with prominent inflammatory changes in the bilateral ureters. Liver biopsy showed myxoid / fibrotic cells, suggestive of resolving abscess. Orange purulent fluid was aspirated with cultures growing Klebsiella oxytoca. Transesophageal echocardiogram ruled out an embolic source. Patient was started on ceftriaxone with interval improvement in liver abscesses two weeks later (Figure 1C). Discussion: This is a case of a young man with recreational ketamine use admitted for sepsis secondary to pyelonephritis and hepatic abscesses. Ketamine is an increasingly common recreational hallucinogen with a well-known complication of ketamine uropathy, which was first reported in Hong Kong in 2007. Common complications include hydronephrosis and pyelonephritis. Cholestatic liver injury can also be seen with elevations in serum alkaline phosphatase and aminotransferase levels, with minimal rise in bilirubin which was seen in in our patient. The radiographic findings on our patient's CT are not typically seen with ketamine use, which is primarily a disease of the intra/extrahepatic biliary tree with focal or diffuse dilation/irregularities. Few cases have reported hepatic abscesses associated with ketamine use. While it is not well known by which mechanism ketamine causes urinary and biliary abnormalities, it is suspected that the altered urinary anatomy and retention, predisposes to pyelonephritis which may seed to the liver resulting in innumerable hepatic abscesses and subsequent sepsis as seen in our patient. Ketamine use should be on the differential for patent’s presenting with urinary retention, hydronephrosis, and hepatic abscesses.Figure 1.: A: No liver cysts or hydronephrosis; B: Multiple liver cysts without biliary ductal dilation. Bilateral hydronephrosis; C: Interval Improvement in hepatic abscesses after antibiotic treatment.