A Complicated Multiloculated Pyogenic Liver Abscess With Spontaneous Rupture and Life-Threatening Hemorrhage...

Pyogenic liver abscess is a severe intra-abdominal infection associated with significant morbidity and mortality, particularly in elderly and comorbid patients. While standard management involves antimicrobial therapy and percutaneous drainage, treatment failure can occur in the setting of multiloculated cavities or resistant polymicrobial infections. Spontaneous rupture of a liver abscess leading to a massive subcapsular hematoma and active hemorrhage is an exceedingly rare but potentially fatal complication. We present the case of an 83-year-old man who presented with sepsis secondary to a large, multiloculated right hepatic abscess. Despite initial broad-spectrum antibiotics and percutaneous drainage, the patient's condition deteriorated. Microbiological analysis, including 16S ribosomal RNA sequencing, revealed a complex polymicrobial infection comprising Pseudomonas aeruginosa, vancomycin-resistant Enterococcus faecium, and Candida species. His clinical course was acutely complicated by the spontaneous rupture of the abscess, resulting in a massive subcapsular hepatic hematoma, active arterial extravasation, and disseminated intravascular coagulation. The patient was successfully resuscitated and managed with urgent interventional radiology-guided transarterial embolization (TAE), which achieved rapid hemostasis and averted the need for high-risk surgical intervention. Following a prolonged multidisciplinary recovery complicated by antibiotic-related hepatotoxicity, he was successfully discharged. This case underscores the critical importance of early recognition of drainage failure, the utility of advanced microbiological diagnostics, and the life-saving role of TAE in managing hemorrhagic complications of hepatic abscesses.