Emphysematous Hepatitis
An 82-year-old man with diabetes, chronic pancreatitis, and biliary strictures presented to the emergency department with a 1-day history of fever and confusion. The heart rate was 150 beats per minute, and the blood pressure was 90/50 mm Hg. On physical examination, he was disoriented, and the right upper quadrant of the abdomen was tender to palpation. The white-cell count was 14,900 per cubic millimeter (reference range, 4000 to 11,000), the aspartate aminotransferase level 1380 units per liter (reference range, 5 to 40), and the alanine aminotransferase level 1121 units per liter (reference range, 5 to 40). A computed tomographic scan of the abdomen obtained after the intravenous administration of contrast material showed a large area of gas in the right hepatic lobe, a finding suggestive of emphysematous hepatitis. Treatment with broad-spectrum antibiotics was initiated, and the patient was admitted to the medical intensive care unit (ICU). A percutaneous hepatic drain was inserted. Blood and fluid cultures grew extended-spectrum beta-lactamase Klebsiella pneumoniae. Emphysematous hepatitis is a rare and fulminant infection of the liver parenchyma that can be seen in patients with diabetes. Despite continued care in the ICU, the patient’s condition deteriorated, and he died on day 8 of hospitalization.