Pyogenic Liver Abscess

likely in at least three of our patients. A precise diagno­ sis is essential, because therapy is radically different between amebic and pyogenic liver abscess. Whereas the majorty of pyogenic liver abscesses will have aspi­ ration or drainage as part of therapy, amebic liver ab­ scesses are best left intact and treated with appropriate antimebicides.7,8 Ready availability and improved reso­ lution of both ultrasound and CT importantly relate to the earlier and more accurate diagnosis of liver abscess.9 Ultrasound is the preferred diagnostic test. It will often identify associated biliary tract abnormality. It is cost effective and remarkably accurate,9 as seen in the 44 abscesses in 47 patients in this series.

Methods We conducted a retrospective analysis of patients with liver abscess and SPE treated at a 2,800-bed medical center in northern Taiwan from January 1, 1999 to December 31, 2005. For the purposes of this study, pyogenic liver abscess was diagnosed if 1 or more areas of hepatic echolucency using ultrasonography or 1 or more hypodense areas of the liver using computed tomography (CT) were observed, and after obtainment of a positive culture from either blood or percutaneous aspiration of the liver abscess or septic metastases. 1 A case definition of SPE was: (1) the presence of lung abscess, multiple round or wedge-shaped dense enti- ties located in the lung periphery; (2) the presence of active extrapulmonary infection as a potential embolic source; and (3) resolution of pulmonary lesions after administration of antimicrobial agents, clearly indicat- ing an infectious cause. 4 In a situation of rapid pro- gression of lung infiltration, SPE was also suggested by the clinical presentation of infectious disease and the results of bacterial culture, either from the embolic source or metastatic sites. We reviewed 831 cases of liver abscess, of which 581 cases had no other intra- abdominal infection and were considered as cases of primary liver abscess. Four hundred and eighteen patients with definite pathogens were considered to

On physical examination, the child was well developed and well nourished. He was febrile with a temperature of 40°C, but other vital signs were normal. There was diffuse gingival redness and swelling with loss of many teeth. He had a diffuse erythem- atous PPK with transgrediens to the dorsae of the hands and feet (Fig 1). He also had multiple, sharply defined, scaly hyperkeratotic plaques over the elbows and knees. The liver was tender and palpable 4 cm below the right costal margin. The spleen was not palpable. Complete blood count, blood chemistry profile, and liver function tests were normal. Blood, urine, and stool cultures were all negative. Abdominal ultrasound and subsequent com- puted tomography (CT) of the abdomen with contrast showed a solitary liver abscess measuring 6 ⫻ 6 cm (Fig 2). Initial differential diagnosis included a pyogenic liver abscess, amebic liver abscess, and Echinococcus granulosus (hydatid cyst); however, the CT scan was not consistent with the characteristics of hydatid cyst. Serum antibody test for Entamoeba histolytica and E granulosus was nega- tive, as well as stool for ova and parasite. Ultrasound-guided drainage was performed, and 100 mL of thick, yellowish exudate was obtained. Staphylococcus aureus, sensitive to cloxacillin and vancomycin and resistant to penicillin, was isolated from the liver abscess culture. Because of the rarity of liver abscess in immuno- competent children, the loss of teeth, and the presence skin le- sions, a dermatology consultation was requested, which estab- lished the diagnosis of PLS.

Eunae Cho 1 † , Sang Woo Park 1 † , Chung Hwan Jun 1* , Sang Soo Shin 2 , Eun Kyu Park 3 , Kyo Seon Lee 4 , Seon Young Park 1 , Chang Hwan Park 1 , Hyun Soo Kim 1 , Sung Kyu Choi 1 and Jong Sun Rew 1 Abstract Background: Transdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied.

Keywords: Hilar cholangiocarcinoma, pyogenic liver abscess, image, simultaneous, surgery Introduction Hilar cholangiocarcinoma (HC) is rare with poor prognosis. Jaundice is the most common pre- senting symptom. The gallbladder is usually vacuous due to the obstruction at the bifurca- tion of the right and left hepatic bile ducts.

The disease underlying HLH was Epstein-Barr virus infection in 2 cases, herpes simplex virus-2 infection in 1 case, parvovirus B19 infection in 1 case, and malignant lymphoma in 1 case. This is the first case report of HLH caused by a pyogenic liver abscess. There are several diagnostic criteria for HLH. Criteria modified from Henter et al. have been widely used, al- though these criteria were mainly composed of data of pediatric HLH cases. Diagnosis of HLH can be made with fever, splenomegaly, unexplained cytopenia affecting at least 2 cell lines, hypertriglyceridemia or hypofi- brinogenemia, hemophagocytosis in bone marrow, spleen, or lymph nodes, low or absent natural killer cell ac- tivity, ferritin 500 ng/mL or more, and elevated soluble CD25 (soluble interleukin-2 receptor) [1].

There is another significant finding of the proposed study, that is, adding GNRI into one model that involves potential risk factors is remarkably superior to adding BMI or serum albumin alone into that model in the aspect of the prediction of adverse outcomes and Table 2 the comparison of the laboratory and liver imaging between high GNRI and low GNRI patients with pyogenic liver abscess

Keywords: Inferior vena caval thrombosis; Pyogenic liver abscess; Thrombectomy Background With increasingly effective diagnostic tools and treatment modalities available, the prognosis of patients with pyo- genic liver abscess (PLA) has improved. However, PLA remains a life-threatening disease with reported mortality rates of 11–31 % [1, 2]. Although PLA can be accompan- ied by a number of complications, such as abscess rupture and metastatic central nervous system infections [3, 4], in- ferior vena caval (IVC) thrombosis is rare. IVC thrombosis can cause pulmonary embolism. Thus far, there has been only one report of an IVC thrombus complicating PLA [5]; therefore, the most suitable and prompt management approach has yet to be established. Here, we present a case of PLA complicated by an IVC thrombus close to the

In terms of causative pathogens, Klebsiella pneumoniae has found as a predominant pathogen, accounting for 50 – 88% of PLA patients who lived Asia during the past two decades [2, 7]. Notably, K. pneumoniae isolating from PLA mainly associates with hypervirulence, with distinct clinical manifestations, as well as phenotypic and geno- typic characteristics [1]. In a recently conducted study, Ye et al. reported that 90.9% of the pathogens causing PLA were hypervirulent K. pneumoniae (hvKp) strains, and there were correlations between the incidences of PLA and high prevalence of hvKp strains [8, 9]. In contrast to classic K. pneumoniae (cKp), the emerging variant, which was first reported in Taiwan in 1986, exhibited hypermu- coviscosity, unique capsular serotype, virulence gene, se- quence type (ST) and resistant spectrum [3]. In addition, hvKp-induced PLA may occur in young and healthy indi- viduals, and then, migrate to distant sites, thereby leading to extrahepatic complications, such as endophthalmitis, meningitis, and necrotizing fasciitis [1, 3]. To date, K. pneumoniae-induced pyogenic liver abscess (KP-PLA) has become a global destructive disease. Therefore, systemic investigations on the clinical and microbiological charac- teristics of recently emerged KP-PLA population are highly essential, for making a comparison with the previ- ously reported ones.

three weeks. The antibiotics used were second to third generation cephalosporins with metronidazole. In the present study of pyogenic liver abscess, percutaneous drainage as the modality of treatment was done in 37% patients. The patients who were subjected to percutaneous drainage responded to this modality of treatment in the following ways, Percutaneous catheter drainage was done in 20 patients, percutaneous needle aspiration done in 17 patients in which, single aspiration in 11 and multiple aspiration 6 patients. The advantages of percutaneous drainage over open surgical drainage are as follows. Little discomfort to patients, minimal interferences with vital function, low cost, no significant peritoneal contamination, minimal contamination of wound. The criticism against percutaneous drainage is; drainage may be inadequate, inability to deal with source of infections, abscesses located anatomically at difficult locations, multiloculated abscess, and thick viscous pus. Laparoscopic drainage was

symptoms of acute infection in the elderly patients are often atypical and misleading. Pyogenic liver abscess (PLA) is an accumulation of pus within the liver as a result of an infection. It accounts for almost half of the visceral abscess cases. Life-threatening sepsis can develop in patients with PLA. Along with the rapid aging population, both the incidence of PLA and the mean age of PLA patients have increased steadily in the past several decades [3, 4]. However, the impact of aging on PLA remains largely unknown. And there are several controversial reports on the clinical characteristics and outcomes of PLA in elderly patients [5–11]. Recent ad- vances in antibiotic therapy, surgical techniques and inten- sive care have markedly improved the outcome of patients with PLA. The purpose of this study was to explore the possible differences in the comorbidity, microbiological characteristics and clinical course between elderly and young PLA patients. Here, we retrospectively analyzed the clinical data of 332 consecutive PLA patients admitted to our hospital and explored the possible differences in the comorbidity, microbiological characteristics and clinical course between elderly and young PLA patients.

A liver-spleen scan was performed because of continued fever associated with minimal right upper quadrant pain and revealed a large intrahepatic filling defect in the lateral aspect of t[r]

phatase, 317 U/liter); the erythrocyte sedimentation rate (127 mm/h) and C-reactive protein (250 mg/liter) were markedly elevated. A chest X ray was unremarkable. Abdominal ultra- sound showed a large multilocular fluid-filled cavity in the right lobe of the liver. The gall bladder was absent, but the biliary tree was normal. Computerized tomographic-guided drainage of the abscess was carried out, yielding more than 200 ml of foul-smelling pus. A drainage catheter was left in situ. Micro- scopic examination of the abscess fluid showed numerous poly- morphonuclear leukocytes but no bacteria or amoebae. Serol- ogy for Entamoeba histolytica was negative. Antibiotic therapy was changed to intravenous ampicillin, ceftriaxone, and met- ronidazole. Following drainage of the liver abscess, the fever abated and the cough and the patient’s general clinical state improved. Intravenous antibiotic therapy was continued for a total of 1 week with a further week of oral ciprofloxacin and metronidazole. After resolution of the liver abscess, a colonos- copy was performed and showed sigmoid diverticular disease with a minor degree of local inflammation.

Overall, the mortality in our cohort is among the lowest reported; only one patient died from multiorgan system fail- ure due to severe sepsis. The low mortality rate observed more specifically in the KLA patient subgroup of our cohort is in keeping with that of other recent reports from Asia 3 and the United States. 11,12 Our findings confirm that the percutaneous approach for liver abscess drainage is safe and effective when combined with appropriate antimicrobial therapy. 15,16 It has been previously reported that the presence of malignancy is a poor prognostic factor in PLA patients. 17 Although 19% of PLA patients in our cohort had cancer, all of them were dis- charged alive. We speculate that the low mortality observed in our cohort reflects the increasing awareness of the disease, early detection, and prompt initiation of appropriate drainage, along with the use of antimicrobial therapy.

Our study has several strengths. Most importantly, it represents an reliable reference for evaluating the initial clinical features of PPLA, providing valuable epidemio- logical information regarding the confirmed PPLA cases in central Taiwan. In addition, the prognostic factors, including the initial presentations, were analyzed. The limitations of this study include the retrospective cross- sectional design. The true prevalence of PPLA may be under-estimated because we collected only the cases with definitive diagnosis and positive microbiological findings in order to reduce potential confounding factors. Every case of polymicrobial liver abscess was considered a single case, with the predominant pathogen determined based on the results of microbiological evaluation. Similarly, only the results of liver abscess pus culture were taken into ac- count if both blood and pus cultures were positive. Fur- thermore, since recurrent PPLA was counted as one case,

Conclusions In conclusion, PLA was mainly due to biliary tract dis- ease with a single lesion located in the right lobe, and the predominant pathogen was K. pneumonia. PLA pa- tients with and without DM had many differing clinical characteristics. PLA patients with DM were older and had more complications including a higher prevalence of cardiovascular disease, a loss of body weight, K. pneumo- nia infections, antibiotic combined therapy with carba- penem, and a greater likelihood of sepsis. In contrast, a history of gastrointestinal surgery and E. coli were less frequent. Furthermore, diabetic PLA patients with poor glycaemic control had a significantly higher proportion of fever and both lobes abscess. Additional large-scale studies and fundamental research can build upon this in- vestigation and should provide further insight into PLA.

Today, surgical treatment of PLA has been relegated in favour of the current frontline treatments of antibi- otics and aspiration/drainage of the PLA [29, 30, 31]. Moreover, laparoscopic drainage of PLA has also re- cently been developed as an option for surgical drainage of liver abscess [32]. Our series also reflected this situ- ation; the first treatment was antibiotics and percutan- eous aspiration/drainage of PLA, followed by antibiotic alone. Few patients received antibiotics plus surgical treatment, and only one underwent laparoscopic drain- age. There were no differences in treatment of PLA be- tween age groups, nor was type of treatment associated with mortality. This observation points to both the ap- propriateness of the treatment and to the fact that thera- peutic efforts are not rationed in older patients.

Table S4) were independently associated with mortality when mutually adjusted. Discussion In our cohort of patients with liver abscess we found no large differences in clinical parameters between pyogenic liver abscess (PLA) and amoebic liver abscess (ALA), other than weak evidence of higher baseline C-Reactive Protein (CRP) for ALA compared with PLA. PLA pa- tients had a 6-month mortality of 15.2% (20/132), whereas no ALA patients died. We found that strepto- cocci were associated with larger abscesses than other bacteria. Baseline ALP and loculation, but not type of microorganism, were associated with increased risk of 6- month all-cause mortality in the PLA group.

decades have facilitated a minimally invasive approach to management of this condition. In combination with targeted antimicrobial therapy, percutaneous drainage techniques now form the mainstay of treatment. How- ever, a small proportion of patients do not respond appropriately to minimally invasive management strate- gies; it is critical to promptly recognize these patients, for whom traditional open surgical intervention is the definitive treatment. We have reviewed our experience in managing pyogenic liver abscess over the last 5 years, to illustrate the current etiology, management and out- comes of this disease. We also reviewed the literature in this field, and present a summary of current practice patterns which may serve as a useful guide for the mod- ern management of pyogenic hepatic abscess.

which had a unpredictable clinical course and was difficult to treatment. The presence of multiple abscess cavities does not preclude the use of PCD, but does necessitate placement of several catheters. 1 In the present case, we performed several PCD catheter exchanges. We initially used only 8 Fr pigtail catheters, which may have been too narrow to drain the thick pus. Although highly successful, PCD fails in approximately 10% cases of pyogenic abscesses. 2 Operative intervention remains the second-line therapy, although surgical treatment should be considered when clinically indicated and in patients with fungal infection. 4 Hope et al 5 stratified 107 patients with pyogenic liver abscess into 3 types: I (small, ,3 cm); II (large, .3cm, unilocular), and III (large, .3 cm, complex multilocular). They proposed a treatment algorithm with small abscesses treated with antibiotics alone; large, uniloculated abscesses treated with percutaneous drainage and antibiotics; and large, multilocu- lated abscesses treated with surgical therapy. In our case, treatment with PCD and antibiotics was successful. Surgical salvage is associated with a high mortality. We were not able to perform surgical open drainage because the patient was already in a consumed condition.