Anupam Kotwal, Kevin Abraham, Maria Garcia and Michael Thompson
Pyogenic liver abscess (PLA) is uncommon in North America. A recent study has reported that persons with diabetes have increased risk of experiencing PLA and a higher 30-day post discharge mortality rate, compared with those without diabetes. Poor glycemic control has been linked to a higher likelihood of gas-forming PLA and metastatic infection due to Klebsiella pneumoniae. Here we present a patient with a history of total pancreatectomy and splenectomy for intraductal papillary mucinous neoplasm (IPMN) complicated by poorly controlled diabetes mellitus, who developed a gas-forming pyogenic liver abscess and was found to have bacteremia with extendedspectrum beta lactamase (ESBL) producing K. pneumoniae. During her hospital course, the abscess changed in appearance to multiloculated. Management was initially with broad spectrum empiric antibiotics, later changed to ertapenem along with abscess drainage. Patients with diabetes are particularly at risk of a gas-forming PLA and may have atypical presentation. Due to significantly increased mortality and morbidity from a gas-forming PLA, empiric antibiotic therapy should be started without waiting for culture results. Improved glycemic control is essential for management because sustained hyperglycemia has been linked to a poor outcome in gas-forming PLA.