S5476 Air Is the Enemy: A Fatal Case of Emphysematous Hepatitis

Introduction: Emphysematous hepatitis (EH) is a rare, life-threatening necrotizing infection of the liver characterized by the presence of gas within the hepatic tissue, without a fluid collection, and after exclusion of iatrogenic, vascular or biliary sources of gas. The diagnosis is often delayed due to non-specific presentation, rapid progression and high mortality rate. The incidence of EH is extremely rare, with only 18 cases reported in the literature. Case Description/Methods: A 79-year-old man with a history of coronary artery disease and prediabetes, presented to the hospital with progressively worsening fatigue, myalgias, and subjective fevers, chills, and abdominal pain. He appeared ill, with jaundice and diffuse abdominal tenderness. He was afebrile, hemodynamically stable. Initial electrocardiogram (EKG) showed sinus rhythm. He had significant leukocytosis to 22,700/μL, normal platelets and international normalized ratio. Total indirect bilirubin were 12.9 mg/dL and 9.7 mg/dL, respectively, aspartate aminotransferase 128 U/L and alanine aminotransferase 95 U/L. CT abdomen showed a focal collection of gas replacing liver parenchyma in the right hepatic lobe segment 7, approximately 5 cm, without any fluid components, vascular gas, or pneumobilia. Blood cultures were sent, and he was started on broad spectrum antibiotics. Unfortunately, over the next few hours, he had worsening hemodynamic status with new atrial fibrillation, hypotension requiring vasopressors. Despite appropriate resuscitation and critical care, he eventually succumbed to PEA cardiac arrest from ongoing fulminant sepsis. The initial set of blood cultures eventually were positive for Clostridium perfringens, confirming the presence of gas-forming organisms. This case was discussed with the multidisciplinary team including diagnostic radiologist who confirmed the presentation and imaging findings were consistent with EH. Discussion: EH is a rare and lethal infection of liver parenchyma caused by bacterial fermentation of necrotic tissue and the production of gases with rapid clinical progression to septic shock and organ failure. Diabetes mellitus is a common comorbidity in patients with EH. The initial management of EH involves aggressive resuscitation and broad-spectrum antibiotics. interventional or surgical drainage of the gas in the liver has been reported with some favorable results. Our case illustrates the rapidity of EH progression as the patient succumbed within hours after presentation to the emergency department, despite prompt imaging diagnosis and initiation of antimicrobial therapy.