Recurrent high grade enterobacter aerogenes bacteremia in a patient with hepatocellular carcinoma

ABSTRACT

INTRODUCTION: Enterobacter species are important nosocomial pathogens. Enterobacter aerogenes is generally found in the human GI tract and does not cause disease in healthy people. We present a case of recurrent enterobacter bacteremia in a patient with hepatocellular carcinoma (HCC). CASE DESCRIPTION/METHODS: A 66 year old male with a history of hemochromatosis, HCC post chemoembolization, hepatitis C, portal vein thrombosis treated with Xarelto who presented with lower abdominal pain, vomiting, and poor oral intake for several weeks. His exam was significant for generalized abdominal tenderness. Vitals, cell counts were unremarkable and LFTs were mildly abnormal with ALP of 436 U/L. CRP was 203 mg/L. COVID-19 PCR negative. Blood cultures were 4/ 4 positive for Enterobacter aerogenes sensitive to ceftriaxone, cefepime, ertapenem and resistant to ampicillin/sulbactam and 1st and 2nd generation cephalosporins. He had been treated with ertapenem for 2 weeks for enterobacter bacteremia with unclear etiology, and the differential at this presentation included vascular infection such as thrombus or infective endocarditis. CT abdomen/ pelvis showed tumor thrombosis versus bland thrombus extending from the ablation field in into the inferior vena cava (IVC). Abdominal MRI confirmed 2.6 cm focus of signal intensity in right hepatic lobe contiguous with non occlusive IVC thrombus. TTE was negative for vegetations. Patient was discharged with 6 weeks of Ertapenem for suspicion of thrombophlebitis given the high grade recurrent bacteremia. DISCUSSION: To date there has been no major case reports or case series demonstrating a case of recurrent high grade enterobacter bacteremia with hepatocellular carcinoma. Spontaneous bacterial peritonitis caused by Enterobacter infections is more commonly associated with underlying HCC and upper gastrointestinal bleeding as compared to infection caused by E coli. For over the last two decades, there has been increasing suspicion about the induction of beta-lactam resistance in enterobacter infections mediated by chromosomally encoded amp-c beta lactamase following antibiotic exposure hence we opted to treat the patient with ertapenem for the 6 week duration. Our case demonstrates a patient with hepatocellular carcinoma with likely/presumed thrombophlebitis requiring prolonged antibiotic course.