S5093 A Rare Case of Septic Shock Secondary to Bacteroides fragilis Empyema in the Setting of Ruptured Liver Abscess

Introduction: Empyema, a severe condition, can rarely arise from liver infections. Bacteria may translocate from the liver to the pleural space through various mechanisms. Bacteroides spp., a virulent anaerobe involved in polymicrobial intra-abdominal infections, can cause significant tissue destruction. This case of Bacteroides fragilis empyema, resulting from a ruptured liver abscess, highlights the uncommon pathophysiological processes by which liver infections can lead to empyema. Case Description/Methods: A 59-year-old man with uncontrolled hypertension, type 2 diabetes mellitus, and alcohol use disorder presented with acute right-sided chest pain radiating to the back, along with shortness of breath, nausea, and fever. He was febrile, hypotensive, and tachypneic. A Computed tomography (CT) scan was performed to rule out aortic dissection, revealing a mild ascending aortic aneurysm (4.1 cm) and a large elliptical fluid collection (9.1 × 4.4 cm) with thick walls and surrounding infiltration posterior to the right hepatic lobe, suggesting a ruptured liver abscess. A right-sided pleural effusion was also noted. Ultrasound confirmed a 9.6 cm fluid collection in the right hepatic lobe, consistent with a liver abscess. The patient underwent interventional radiology-guided liver abscess drainage and thoracentesis. Gram stain of the pleural fluid revealed gram-negative bacilli and gram-positive cocci in clusters. Cultures identified Bacteroides spp. and Staphylococcus warneri, confirming empyema secondary to the ruptured liver abscess. Initially, the patient received broad-spectrum intravenous antibiotics, including piperacillin-tazobactam, which was later narrowed to ampicillin-sulbactam based on culture sensitivities. Despite initial improvement, the patient continued to show signs of sepsis, necessitating video-assisted thoracoscopic surgery (VATS) with decortication for definitive management. Post-VATS, the patient recovered significantly and was discharged on oral antibiotics to complete the treatment. Discussion: This case illustrates a rare complication of a ruptured liver abscess leading to empyema. While liver abscesses often result in sepsis or peritonitis, translocation of bacteria to the pleural space is uncommon but life-threatening. The virulence of Bacteroides spp. underscores the critical nature of this infection. Timely diagnosis through imaging and microbiological analysis, coupled with antibiotics and surgical drainage, is crucial for successful management.