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Sepsis from liver abscesses in metastatic colorectal carcinoma after chemoimmunotherapy.

A 60-year-old patient receiving palliative chemoimmunotherapy for adenocarcinoma of the coecum with liver and lung metastases presented repeatedly with fever and sepsis after chemoimmunotherapy. After each course of chemoimmunotherapy consisting of bevacizumab, capecitabine, and oxaliplatin, the patient was admitted with sepsis during two consecutive sessions with signs of fever and hypotension (a blood pressure of 80/40 mmHg). Laboratory values showed an elevated sedimentation rate (109 mm/h), C-reactive protein (717 mg/L), and marked leukocytosis (28 109/mL; 2% bands and 77% segments). Repeated blood, urine, and fecal cultures were all negative during his first two admissions, but the patient responded well to the instituted antimicrobial therapy, including metronidazol. An ultrasound of the abdomen was also taken during this period, but did not show any infection. After the second course of chemoimmunotherapy and recovery of his second septic episode, a computed tomography (CT) scan of the chest and abdomen was taken to evaluate the therapeutic response to the chemoimmunotherapy. Multiple hypodense liver lesions were identified consistent with necrotic metastases (Fig 1A). No new lesions were detected and, therefore, the cause of the sepsis was not identified. However, after his third course of chemoimmunotherapy, the patient was readmitted with relapsing fever and blood cultures tested positive for Bacteroides fragilis. A repeat CT scan of the abdomen showed a new hypodense lesion located in the right liver lobe (Fig 1B, arrow). The characteristics of this new lesion on CT scan were similar to the known necrotic liver metastasis. Based on the clinical setting with a good therapeutic response, such as a decrease in carcinoembryonic antigen levels, the diagnosis of liver abscess was suggested. This new lesion was shown by ultrasonography to be of a liquid consistency (Fig 1C) as opposed to the necrotic liver metastasis, which still showed some solid components. The pus obtained through a percutaneous diagnostic aspiration of the abscess proved to be a liver abscess because on culture it grew Bacteroides fragilis. This minimally invasive procedure, however, resulted in another septic episode requiring volume suppletion, despite antibiotic treatment including cefuroxim and metronidazol started several days before percutaneous intervention. After 2 weeks of continued antibiotic treatment and insufficient abscess size reduction, successful therapeutic percutaneous drainage was performed. Our patient received his other sessions without reoccurrence of septic episodes. Extraintestinal manifestations of occult colon carcinoma are well documented, for example, endocarditis with Streptococcus bovis species, a condition necessitating a search for an occult colon carcinoma. Other manifestations such as arthritis, liver abscess, and septic pericarditis with cardiac tamponade are lesser known. These conditions have all been reported involving Bacteroides fragilis, an anaerobic organism frequently associated with colon carcinoma. Liver abscesses in necrotic liver metastasis infected by primarily anaerobic microorganisms have been described, but are extremely rare; approxiA