Recurrent Primary Suprahepatic Abscess Due to Providencia Stuartii: A Rare Phenomenon

Abstract

Gram-negative urease-producing bacilli, Providencia stuartii (P. stuartii), is reported in urinary tract infections, gastroenteritis, and bacteremia in humans but they rarely present with a hepatic abscess. We present a rare case of a recurrent suprahepatic cyst due to P. stuartii in a 45-year-old female, intravenous ( IV) heroin abuser with chronic hepatitis B and C.A 45-year-old female with 10 days status post right suprahepatic abscess drainage presented with recurrent, right, upper quadrant abdominal pain for one day. The pain was 7/10, sharp, radiated to the right back, and was associated with nausea, non-bloody non-bilious vomiting, and right-sided pleuritic chest pain. She was discharged after interventional radiology (IR) drainage of the abscess and completed 14 days of levofloxacin and metronidazole. On palpation, mild tender hepatomegaly was noticed. Complete blood count showed leukocytosis of 17.1 with left shift but liver enzymes within normal limits. Aspirated fluid cultures from the abscess showed P. stuartii. Blood and urine cultures were negative. A human immunodeficiency virus (HIV) test was negative. Hepatitis B virus (HBV) deoxyribonucleic (DNA) polymerase chain reaction (PCR) showed > 17 million IU/ml and hepatitis C virus (HCV) Ab reactive. A right, upper quadrant sonogram showed 4.1x0.9x2.7 cm fluid collection anterior to the right liver lobe. A computed tomography (CT) abdomen showed a dominant 5.2x5.5x3.9 cm hypodense lesion consistent with an abscess above the right liver. Initially, she was treated empirically with IV piperacillin-tazobactam and anticoagulation for a pyogenic liver abscess (PLA). Clinical and laboratory improvement were achieved with intravenous antibiotics evidenced by the decreasing size of the abscess on repeat CT scan. The patient was discharged with continuing antibiotics after four weeks. Repeated CT scan showed complete resolving of the suprahepatic cyst.In conclusion, in our patient, long-term shelter residence, IV heroin use, and chronic hepatitis B and C might be precipitating factors for PLA. Managing a recurrent primary hepatic abscess caused by P. stuartii is similar to PLA from other bacterial causes: drainage and antibiotic therapy. However, in our case, she responded well to medical treatment without further surgical drainage.

Clinical and drug resistance characteristics of Providencia stuartii infections in 76 patients

“…The treatment of choice is based on antibiotic sensitivities, infection source, and comorbid conditions. 3 …”

“…The antibiotic resistance of P. stuartii is remarkable: 82% of isolates are resistant to amoxicillin-clavulanate, 40% are resistant to ampicillin-sulbactam, 80% are resistant to gentamicin, and 84% are resistant to ciprofloxacin. 3 P. stuartii is therefore difficult to treat; moreover, it is frequently involved in nosocomial outbreaks, particularly in nursing homes, burn wound units, and critical care units. P. stuartii infections are often difficult to control and have substantial impacts on patient morbidity, mortality, treatment, and management costs.…”

“…The treatment of choice is based on antibiotic sensitivities, infection source, and comorbid conditions. 3 Currently, the prevalence of P. stuartii infection is increasing because of antibiotic resistance secondary to the presence of extended spectrum beta-lactamase (ESBL) enzymes. The antibiotic resistance of P. stuartii is remarkable: 82% of isolates are resistant to amoxicillin-clavulanate, 40% are resistant to ampicillin-sulbactam, 80% are resistant to gentamicin, and 84% are resistant to ciprofloxacin.…”

Investigation of factors related to biofilm formation in Providencia stuartii

“…The species P. stuartii being one of the most frequent and widely associated with urinary tract infections, especially in patients undergoing long periods of catheterization (Armbruster et al 2014, Kurmasheva et al 2018. As it is an opportunistic pathogen, this bacterium can cause other infections: septicemia (Aires et al 2016), diarrhea (Shima et al 2016), pneumonia (Abdallah & Balshi 2018, infections in burns and open wounds (Pirii et al 2018, Libertucci et al 2019, even those uncommon for this species, such as conjunctivitis (Crane et al 2016), liver abscesso (Lin et al 2017), rectal abscesso (Lee et al 2017), and septic vasculitis (George et al 2020).…”

Bronchopneumonia in sheep associated with Providencia stuartii

“…In humans, this bacterium has been isolated mainly from patients with chronic urinary tract diseases who are subjected to prolonged use of catheters (Barl et al, 2012;Wie, 2015). However, reports of the presence of renal and hepatic abscesses (Chamberland et al, 2013;Lin et al, 2017), meningitis (Sipahi et al, 2010), endocarditis (Krake & Tandon, 2004), conjunctivitis (Crane et al, 2016) and septic vasculitis (George et al, 2020) have also been described in the literature.…”