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INTRODUCTION: Klebsiella pneumoniae is a gram-negative bacterium, native to the common flora of the human digestive tract and skin. This organism can cause opportunistic infection in at risk populations, such as those who are immunocompromised. Less commonly, monomicrobial abscess formation can develop without underlying hepatobiliary disease. CASE DESCRIPTION/METHODS: A 76-year-old Polish male presented for the evaluation of worsening mentation, generalized weakness and anorexia that began two months prior to presentation. The patient was admitted when Chest X-ray revealed a near complete opacification of the right hemithorax. CT imaging of both chest and abdomen/pelvis were obtained showing a large, loculated pleural effusion of the right lung as well as findings consistent with a probable liver abscess. Intra-operatively, an associated diaphragmatic fistula was repaired, two right sided chest tubes were placed. Cultures of both pleural and hepatic fluid collections yielded Klebsiella pneumoniae. Blood and urine cultures remained negative. CT Brain was obtained and negative for acute findings. ENT was also consulted to rule out endophthalmitis. The patient continued to clinically improve with supportive care and IV antibiotics. Approximately one week after surgery, chest tubes were removed and the patient was discharged home to complete IV antibiotic therapy. DISCUSSION: This case highlights a rare formation of liver abscess with hepatothoracic fistulation in an immunocompetent patient, of non-Asian descent, without underlying hepatobiliary disease. Pyogenic liver abscess is usually associated with complication from intra-abdominal or hepatobiliary disease. Infection from monoisolate Klebsiella pneumoniae has been increasingly prevalent in the Taiwanese population and extensively studied among certain Asian demographics. It has been postulated that some groups may be predisposed to intestinal colonization of more invasive Klebsiella species, suggesting a possible genetic etiology. Metastatic infection secondary to particularly virulent strains, K1/K2 capsular serotypes, can be potentially life-threatening as it is associated with CNS infection and endophthalmitis. Thus far, regional distribution of KLA shows a preference for South Africa and Taiwan. With the rising epidemic of obesity and insulin resistance in the United States, we encourage clinicians with similar presentations to consider possible KLA infection. Early identification and eradication of the infection is key in preventing fatal outcomes.

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Dieulafoy’s lesion is a rare cause of gastrointestinal (GI) bleeding comprising approximately 2% of all acute GI bleeds. It is an abnormal submucosal artery that has a tortuous course before protruding through the mucosa and leading to hemorrhage. Dieulafoy’s lesions are most commonly located in the upper GI tract within the lesser curvature of the stomach. Lower GI tract Dieulafoy’s lesions are remarkably rare. Our case describes an elderly gentleman who presented with fatigue and dyspnea several days prior to experiencing any evidence of GI bleeding. Initial laboratory investigation revealed severe anemia, requiring packed red blood cell transfusion. Endoscopic examination revealed a cecal Dieulafoy’s lesion with active spurting of blood. Hemostasis was achieved through local epinephrine injection and hemostatic clipping. Previously reported cases of cecal Dieulafoy’s lesions involve variable presentations including hematochezia, melena, or bright red blood per rectum. These lesions can be treated by angiography, surgically, or endoscopically via techniques that include epinephrine or ethanol injection, argon plasma coagulation, heater probe coagulation, hemostatic clips, or band ligation. Dieulafoy’s lesions of the lower GI tract should be considered when no clear culprit is discovered, particularly with the concomitant use of antiplatelet agents and anticoagulants.