THE TRUTH THE TEETH TOLD: THE UNUSUAL CASE OF A SUBPHRENIC MASS

ABSTRACT

CASE A 75-year-old man with a history of aortic stenosis status post transcatheter aortic valve replacement (TAVR), compensated cirrhosis in the setting of alcohol use disorder, and osteoarthritis presented with hyper-acute dyspnea and chest pain that awoke him from sleep. Three years prior to admission, an abdominal computed tomography (CT) for his TAVR evaluation revealed a 2 cm, irregular, peripherally-enhancing mass in the right subphrenic space, most concerning for malignancy but stable in size a year later. Further work-up was delayed due to the COVID-19 pandemic. One week prior to this presentation, he returned to care with 6 months of progressive right shoulder pain, pleuritic chest pain, and 5 kg of unintentional weight loss and was found to have growth of the right subphrenic mass to 4.9 cm, for which he underwent interventional radiology-guided aspiration and biopsy from a subxiphoid approach. Pathology on the core biopsy was inconclusive, revealing granulation tissue with chronic inflammatory changes and negative routine cultures. He was hemodynamically stable and discharged home. On admission, he was afebrile, tachypneic to 26, tachycardic to 120, hypotensive to 80/40, and saturating 94% on room air. He was found to have a large pericardial effusion with tamponade physiology, upon which 500 mL of serous fluid was drained via emergent pericardiocentesis. Laparoscopic biopsy of the subphrenic mass revealed a purulent fluid collection. 16S/18S sequencing and MALDI cultures were most consistent with Actinomyces spp. With further history-taking alongside an Italian language interpreter, he was found to have had prior dental abscesses, the likely origin of his Actinomyces infection, although the curious propensity for the subphrenic location remains unknown. Periodontal disease had been diagnosed but not fully treated given lack of insurance coverage and perceived importance. His pericarditis and ensuing tamponade was attributed to irritation and seeding from the subxiphoid approach for attempted fluid aspiration. IMPACT/DISCUSSION: Actinomyces spp. are a part of the normal human gut and oral cavity flora, but when pathogenic, they are often associated with dental, pulmonary, and urinary tract infections. In addition to periodontal disease, this patient's risk factors for Actinomyces abscess formation include cirrhosis (via transient gut translocation from elevated portal pressures) and alcohol use disorder (via increased aspiration risk). There have been several reports of Actinomyces spp. causing pericarditis and tamponade following seeding from liver, lung, and oral cavity abscesses- to our knowledge, however, none from subphrenic abscesses. CONCLUSION: This case highlights the importance of an oral health history in work-up of an indolent growing thoracic mass and the challenges in comprehensive history-taking in patients with limited English proficiency. Increasing coverage of dental services (e.g. a Medicare dental benefit) is key to health and health equity.