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

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.