Severe acute respiratory distress syndrome due to fusobacterium nucleatum liver abscess

SESSION TITLE: Chest Infections Case Report Posters 10 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Fusobacteriae are anaerobic gram-negative bacilli, most well-known for oropharyngeal and endodontic infections, and classically involved in septic thrombophlebitis in Lemierre's syndrome. We describe a case of fusobacterium liver abscess that presented with acute hypoxic respiratory failure, progressing to severe acute respiratory distress syndrome (ARDS). CASE PRESENTATION: A 30-year-old male without significant past medical history presented with fever, chills, myalgias, dry cough and shortness of breath for 9 days. He denied any other symptoms and no recent travel history.On presentation, his blood pressure (BP) was 105/57 mmHg, heart rate (HR) was 123 beats per minute (BPM), respiratory rate (RR) of 19, O2 saturation was 85% on room air, and temperature was 38.6 C. He had normal heart sounds and bilateral crackles on lung auscultation. Abdomen was soft and nontender. There was no peripheral edema. Lab investigations revealed leukocytosis and mild transaminitis. COVID, influenza and RSV were negative.Chest x-ray on admission showed mixed interstitial and air space opacities (Figure, A). He was diagnosed with community-acquired pneumonia and started on ceftriaxone and azithromycin. Over the next 24 hours, he developed worsening dyspnea and hypoxia, requiring the use of high flow nasal cannula. He was admitted to the intensive care unit, where repeat chest x-ray showed increased bilateral lung opacities (Figure, B). His antibiotic coverage was broadened to vancomycin, piperacillin-tazobactam, along with azithromycin. Ultrasound of liver showed hepatomegaly with liver measuring 19.7 cm with homogeneous texture. CT chest showed near complete consolidation of the lower lobes with moderate patchy airspace opacities in the remaining lobes (Figure, C). CT abdomen showed a 6.2 cm heterogeneous lesion at the right hepatic dome, favored to represent hepatic abscess (Figure, D).Over the next few hours his respiratory status worsened and he continued to spike high fevers. He was intubated due to hypoxia and high work of breathing. Shortly after, he was proned due to hypoxia despite adequate sedation and neuromuscular blockade, with improvement in his oxygenation.CT-guided aspiration and drain placement removed 20 ml of cloudy, bloody fluid. Gram stain was negative. He continued to spike high fevers (T max 40.6 oC ), and transaminitis worsened peaking at AST 226, ALT 272 and bilirubin 5.8 (direct 5.0), after which it started to improve. Over the course of 3 days he slowly improved and was extubated after 72 hours of intubation. Fusobacterium nucleatum was isolated from the fluid culture after 10 days of incubation. After resolution of fevers, the drain was removed and patient was discharged on oral ciprofloxacin and metronidazole. Outpatient CT abdomen showed radiographic resolution of the abscess after 10 weeks of antibiotics therapy. DISCUSSION: F. nucleatum is a rare cause of pyogenic liver abscess with may occur in immunocompetent patients, likely due to hematogenous spread from an oral or gastrointestinal source. Treatment involves a prolonged course of antibiotics until radiographic resolution. CONCLUSIONS: F. nucleatum often results in a syndrome of fever, chills and abdominal pain, but occasionally results in a florid picture of sepsis and ARDS. REFERENCE #1: Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. Oct 2012;12(10):808-15. doi:10.1016/s1473-3099(12)70089-0 REFERENCE #2: Jayasimhan D, Wu L, Huggan P. Fusobacterial liver abscess: a case report and review of the literature. BMC Infect Dis. Jun 20 2017;17(1):440. doi:10.1186/s12879-017-2548-9 DISCLOSURES: No relevant relationships by Ali Abdelhay No relevant relationships by Omar Al Ali No relevant relationships by Pratibha Chaudhary No relevant relationships by Ahmed Elkhapery No relevant relationships by Michael Gurell No relevant relationships by Tripti Jain No relevant relationships by Maryrose Laguio-Vila No relevant relationships by Soon Khai Low No relevant relationships by Sheza Malik No relevant relationships by Chengu Niu No relevant relationships by Abdullah Orakzai No relevant relationships by Carlos Portales-Castillo No relevant relationships by Qian Zhang