Clinical features and development of Sepsis in Klebsiella pneumoniae infected liver abscess patients: a retrospective analysis of 135 cases

Background

Klebsiella pneumoniae is a primary pathogen of pyogenic liver abscess (PLA). However, little data are available on combination with sepsis. In this study, we aimed to evaluate the clinical characteristics and prognostic differences of PLA patients with sepsis.

Methods

This retrospective cohort study was conducted to investigate 135 patients with confirmed Klebsiella pneumoniae-caused liver abscesses (KPLA) from a tertiary teaching hospital, from 2013 to 2019. The patients were divided into two groups, KPLA with sepsis and KPLA without sepsis. The demographic characteristics, clinical features as well as laboratory and microbiologic findings were analyzed.

Results

A total of 135 patients with KPLA were analyzed. The mean age of patients was 60.9 ± 12.7 years, and the percentage of men was 59.3%. Among them, 37/135 (27.4%) of patients had sepsis and the mortality rate was 1.5%. The most common symptom was fever (91.1%). KPLA patients with sepsis had a significantly higher proportion of frailty, diarrhea, fatty liver, chronic renal insufficiency, and hepatic dysfunction compared to KPLA patients without sepsis (p < 0.05). Antibiotic therapy and percutaneous drainage were most frequently therapeutic strategy. Furthermore, the incidences of sepsis shock and acute respiratory distress syndrome were higher in the sepsis group compared to the non-sepsis group. As for metastatic infections, the lung was the most common site. In addition, KPLA patients with sepsis showed respiratory symptoms in 11 patients, endophthalmitis in 4 patients, and meningitis in 1 patient.

Conclusion

Our findings emphasize that KPLA patients combined with or without sepsis have different clinical features, but KPLA patients with sepsis have higher rates of complications and metastatic infections. Taken together, further surveillance and control of septic spread is essential for KPLA patients.

Importation of Entamoeba histolytica and predominance of Klebsiella pneumoniae in liver abscesses: a 7-year retrospective cohort study from the United Arab Emirates

BACKGROUND

There is a dearth of information on liver abscesses in the United Arab Emirates. Herein, we describe the clinical features of liver abscesses and determine their incidence rates and clinical outcomes.

METHODS

We retrospectively reviewed the clinical charts of adult patients with a primary diagnosis of liver abscess at a major hospital over a 7-year period.

RESULTS

Amongst 45 patients, 82.2% (37/45) had a pyogenic liver abscess (PLA) and 17.8% (8/45) had amoebic liver abscesses (ALA). Overall, patients were young (median age 42 years, IQR 35-52), mostly males (77.8%, 35/45) from the Indian subcontinent (55.6%, 25/45), presented with fever (88.9%, 40/45) and abdominal pain (88.9%, 40/45), and had a solitary abscess on imaging (71.1% (32/45). Crude annual incidence rates were 35.9/100,000 hospital admissions (95% CI 26.2-48.0) and 5.9/100,000 inhabitants (95% CI 4.3-7.9). All ALA patients were from the Indian subcontinent (100%, 8/8). Klebsiella pneumoniae was the most frequent pathogen in PLA (43.2% [16/37], 95% CI 27.1-60.5%). The hospital stay was shorter in ALA (7.5 days, IQR 7-8.5) than in PLA (14 days, IQR 9-17). No deaths were recorded within 30 days of hospitalisation.

CONCLUSIONS

ALA was exclusively seen in migrants from the Indian subcontinent, suggesting importation. Further research to characterise K. pneumoniae isolates and assess potential risk factors is needed.

A fatal case of liver abscess caused by hypervirulent Klebsiella pneumoniae in a diabetic adolescent: A clinical and laboratory study

IMPORTANCE

Hypervirulent variants of Klebsiella pneumoniae (hvKp) are capable of causing life-threatening pyogenic liver abscesses (PLAs), but hvKp caused PLAs was seldom reported in pediatric populations. Hence, there is an urgent need to raise our awareness of this phenomenon in pediatric populations.

OBJECTIVE

This study aimed to report the clinical characteristics of hvKp that caused fatal PLA complicated by bacteremia in an adolescent and further identify the microbiological and genomic features of the causative strain.

METHODS

A 14-year-old boy with diabetes mellitus was admitted to our hospital with a diagnosis of PLA complicated by bacteremia. A hypermucoviscous hvKp strain, KPN_19-106, was isolated from the drainage fluid present within the liver abscess cavity and blood. The hypermucoviscosity phenotype of the causative strain was determined by string test. Its virulence was measured using serum resistance assay and Galleria mellonella larvae-killing assay. Antimicrobial susceptibility was determined by broth microdilution method. Genetic information was obtained by whole-genome sequencing and bioinformatics analysis.

RESULTS

KPN_19-106 belonged to sequence type 380 and serotype K2 and exhibited stronger serum resistance and higher in vivo lethality than the well-characterized hvKp NTUH-K2044 strain. Although KPN_19-106 is susceptible to most antibiotics, no sign of improvement was observed during treatment with such drugs. Whole-genome sequencing revealed that the isolate had integrated multiple mobile genetic elements related to virulence.

INTERPRETATION

Antibiotic-susceptible hvKp can cause fatal PLA complicated by bacteremia in adolescents, with no improvement during antimicrobial therapy. The causative strain in this case had integrated multiple virulence genes and thus exhibited higher virulence both in vitro and in vivo when compared with NTUH-K2044.

A novel case of Raoultella bacteremia secondary to liver abscess formation following transarterial chemoembolization

Raoultella planticola is an uncommon gram-negative bacterium that has rarely been identified as the causative organism in severe infections. Few cases have been described and have included patients with pneumonia, urinary tract infections or cholangitis. Only one case has reported to involve a liver abscess, thought to be from a primary urologic source. We describe the case of a 73-year-old man with recently diagnosed hepatocellular carcinoma who developed multiple pyogenic liver abscesses. The abscesses were thought to have developed in the setting of recent transarterial chemoembolization leading to R. planticola bacteremia noted on admission. Treatment with ceftriaxone and metronidazole was initiated in addition to drainage of the abscesses, resulting in decreased size of liver collections and initial clinical improvement. R. planticola remains a rare infectious organism in severe infections affecting both immunocompromised and immunocompetent individuals. Our patient’s underlying malignancy and recent transarterial chemoembolization likely placed him at risk of liver abscess formation complicated by bacteremia and sepsis.

Stenotrophomonas maltophilia: An uncommon cause of liver abscess

We report an uncommon case of pyogenic liver abscess due to Stenotrophomonas maltophilia in an apparently immune-competent individual, the timely recognition of which could avoid a potentially fatal course of infection in the patient. A 45-year-old man, with history of moderate alcohol intake since the last 10 years, was admitted with intense right-sided upper abdominal pain and right-sided chest pain of 10-days duration. Culture of the ultrasound-guided liver aspirate sample yielded a pure growth of S. maltophilia identified by the VITEK-2™ automated microbial identification system. Treatment with parenteral levofloxacin and oral trimethoprim-sulfamethoxazole along with pigtail catheter drainage and other appropriate supportive management led to resolution of the abscess with no recurrence of infection at two months follow-up. Physicians need to be aware that S. maltophilia infections may not be restricted to hospitalized patients as a low-virulence opportunistic pathogen, but may occur as an important emerging pathogen in community-acquired infections as well.

Association of blood culture with carbapenem use in pyogenic liver abscess: a two-center retrospective study

Background

Highly empiric use of carbapenem in pyogenic liver abscess (PLA) is widespread problem. However, few studies have examined the association between blood culture and carbapenem use in patients with PLA in China. Thus, we conducted this observational study.

Methods

The data of patients diagnosed with PLA at two comprehensive tertiary care centers from 2014 to 2020 were retrospectively collected. Demographic and clinical data were analyzed, and univariate and multivariate analyses were performed to investigate the association between blood culture and carbapenem use. Subgroup analysis was conducted to explore whether the effect is different in sepsis.

Results

Blood culture was performed in 110 (46.0%) patients, of whom 44 (40.0%) patients had positive results for bacterial culture. Extended-spectrum beta-lactamase (ESBL)-positive blood culture isolates were detected in 8 (7.3%) patients. The positivity rate of blood culture in sepsis was higher than in non-sepsis (58.1% vs. 32.9%, P = 0.015). Fewer patients who had a blood culture received carbapenem treatment in comparison to patients without blood culture (19.1% vs. 31.8%, P = 0.026). Multivariate analysis showed that blood culture was independently associated with less carbapenem exposure (adjusted odds ratio [OR] = 0.33, 95% confidence interval [CI]: 0.16–0.68, P = 0.003), and this effect remained significant in the sepsis subgroup (adjusted OR = 0.17, 95% CI: 0.05–0.53, P = 0.002).

Conclusion

Blood culture had a high positivity rate and was associated with less carbapenem use in PLA, especially those who developed sepsis. More attention should be paid to performing early blood culture and less carbapenem use in PLA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00442-2.

[Advances in the study of occult malignant tumor-related pyogenic liver abscesses in the digestive system]

Pyogenic liver abscess (PLA) accompanied by occult malignant tumors is a rare kind of life-threatening disease. Studies have shown that it can predict the occurrence of cancer, especially hepatobiliary and colorectal cancer. The risk of combined occult primary liver cancer, cholangiocarcinoma, and gastrointestinal cancer is high in PLA patients. Malignant tumor-related PLA lacks specific symptoms and signs. The iodine concentration ratio between the energy spectrum CT lesions and normal liver tissue is of certain value in the differentiation of liver cancer and liver abscess. Computed tomography colonography has a dual role. It can screen patients with PLA for occult colorectal cancer and determine the treatment response of abscess lesions. Klebsiella pneumoniae and Escherichia coli is the main microorganism of PLA related to colorectal cancer, hepatocellular carcinoma, and intrahepatic cholangiocarcinoma. PLA treatment related to hepatobiliary malignant tumor has high complications and mortality, and poor prognosis. Most occult colorectal cancers are in the early stage, and their early detection and prognosis are better than those of PLA patients combined with hepatobiliary malignancies.

Pyogenic liver abscess caused by Fusobacterium nucleatum with an inflammatory scar in the abdominal cavity

Pyogenic liver abscesses generally occur secondary to spread from active infective lesions. We report a rare case of liver abscess in a patient without a clear source of infection. A 19-year-old man was diagnosed as having a liver abscess after investigations when he presented with chief complaints of fever and lethargy. Fusobacterium nucleatum was detected in the pus culture taken from the abscess that was drained. His condition improved with antibacterial treatment. Further examination of the gastrointestinal tract suggested that the infection had tracked through the portal vein from a scar between the rectal sigmoid and the appendix. Laparoscopic adhesiolysis and appendectomy were performed to treat the same. Fusobacterium can be identified early by Gram staining of pus from the liver abscess, which is useful for treatment. In young people with pyogenic liver abscess due to Fusobacterium nucleatum who are not immunocompromised, examination of the gastrointestinal tract should be considered to determine a cause.

Multiple septae as potential protective factors against spontaneous pyogenic liver abscess rupture: a propensity score matching analysis

PURPOSE

The symptoms of spontaneous rupture of a pyogenic liver abscess (PLA) are severe and often life-threatening. Multiple septae are important imaging features of PLA. However, the relationship between septation and abscess rupture is still under debate.

METHODS

Patients diagnosed with PLA from January 2011 to November 2019 in our hospital were included. We collected demographic, clinical, and computed tomography data. Univariate and multivariate analyses determined liver abscess rupture risk factors. The relationship between multiple septae and abscess rupture was evaluated by propensity score matching after matching other influencing factors.

RESULTS

A total of 583 patients of pyogenic liver abscesses were included in the study: 30 ruptured and 553 unruptured. Multivariate analysis revealed diabetes, single lesion, gas formation, left hepatic lobe location, and a diameter > 66.5 mm as independent risk factors for ruptures, while multiple septae were identified as a protective factor. After matching all the influencing factors (excluding multiple septae), multiple septae and abscess rupture maintain a negative relationship.

CONCLUSIONS

Multiple septae were identified as a potentially protective factor against spontaneous pyogenic liver abscess ruptures.

Retrospective study of characteristics and management of pyogenic liver abscess during 5 years' experience

Pyogenic liver abscess is a life-threatening disease. It is urgent to review the clinical patterns, risk factors, and management of the disease in order to improve the outcome. We retrospectively analyzed 70 cases of pyogenic liver abscess diagnosed and treated at Shanghai Ninth People's Hospital over five years, including the clinical features, management, and outcome. The average age was 63.06 ± 12.33 y. 71.4% (50/70) were males. 85.7% (60/70) patients presented with fever. The major abnormalities in laboratory were increased CRP and liver dysfunction. 77.8% (14/18) pus cultures came with positive reports, while 26.5% (9/34) blood cultures were positive. K. pneumoniae was the predominant pathogen both in blood (66.7%, 6/9) and pus (64.3%, 9/14) cultures. 42.9% (30/70) patients also had diabetes. Patients with diabetes presented with significantly larger size of abscess (P = 0.014) and were more susceptible to K. pneumoniae infection (P = 0.002). We revealed HbA1c (P = 0.047), accompanying malignancy (P = 0.030), and septic shock (P = 0.045) were three independent risk factors for PLA. In conclusion: pyrogenic liver abscess was atypical; microbiologic positivity of pus culture was higher than that of blood culture; K. pneumoniae was the predominant pathogen in pyrogenic liver abscesses, especially in patients with diabetes; and patients with hyperglycemia had poor outcome.

Epidemiological, Clinical, Microbiological, and Risk Factors of Pyogenic Liver Abscess: An 18-years Retrospective Single-Center Analysis

Background: A pyogenic liver abscess (PLA) is the most frequently observed subtype of liver abscess in the western world. The disease has been subjected to a remarkable change. We aimed to investigate the recent trend in pyogenic liver abscess’s epidemiology, clinical, microbiological, and risk factors features.Methods: A retrospective analysis of medical records was done for the patients diagnosed with PLA from January 2000 to June 2018. The institutional review board approved the study.Results: We identified 113 patients with PLA, 60% were males, with a mean age of 54 ± 20 years, and 58 ± 19 years old for males and females, respectively (p = 0.298), with an increasing annual incidence in 2012–2013, and 2016–2017 (Figure 1). Fever and right upper quadrant abdominal pain were the most common symptoms (65%, 55%, respectively). Forty percent of the patients had Biliary tract diseases like cholecystitis or biliary intervention as cholecystectomy or ERCP, and 20% had diabetes mellitus (Table 1). The abscess culture was obtained in 96 cases, 37 cases were negative (39%), 27 cases showed polymicrobial growth (28%) and 15 cases showed Escherichia coli (16%) (Figure 2). The abscess cultures were mostly negative in the first 5 years, then changed to Streptococcus anginosus, and polymicrobial growth in the last four years.Conclusions: PLA is more common in males with a recent increase in incidence. Culture negative PLA was observed in patients who were empirically treated with antibiotics. Polymicrobial was the most common identifiable organism with a change in the microbiological trend every 5 years.

Unusual pneumoperitoneum secondary to ruptured liver abscess-A case report

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Pneumoperitoneum secondary to ruptured gas containing pyogenic liver abscess is rare.

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Klebsiella is frequently associated with gas-forming abscesses.

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Ultrasound and CT are the mainstays of diagnostic modalities for hepatic abscess.

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Surgery is essential to drain the abscess and to clean the contaminated abdominal cavity for a ruptured abscess.

Introduction

Pyogenic liver abscess is important cause of hospitalization and life threatening disease in low-middle income countries. Clinical spectrum of ruptured GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis.

Case presentation

We reported here a case with pneumoperitoneum caused by ruptured liver abscess in a 27-year-old man with a history of uncontrolled type II diabetes mellitus. He had an abdominal pain, distension of abdomen associated with a high fever. Patient was diagnosed peritonitis and pneumoperitoneum presumed to be secondary to perforation of a hollow viscus and subjected to emergency laparotomy. We did not find any gastrointestinal perforation. Surprisingly, we detected a ruptured liver abscess in the right lobe of the liver.. The patient was in septic shock and hence shifted to ICU with inotropic support. Antibiotic therapy was started according to pus culture sensitivity. Even with the above treatment patient was not improved and on 4th postoperative day the patient collapsed and declared dead.

Discussion

Pneumoperitoneum secondary to ruptured gas containing pyogenic liver abscess is rare and could represent as life threatening infection. It should be distinguished from perforation of hollow organ by clinical symptoms and image examinations, particularly like CT. Accurate diagnosis with adequate drainage and antibiotic therapy would bring good outcome.

Conclusion

We are aware that not every case of pneumoperitoneum is attributable to a perforated hollow viscus. A rapid and prompt surgical intervention with appropriate antibiotics are essential to save a life.

Endogenous endophthalmitis in Klebsiella pneumoniae pyogenic liver abscess: Systematic review and meta-analysis

BACKGROUND

Endogenous endophthalmitis (EE) is a devastating complication that develops as a metastatic infection in patients with Klebsiella pneumoniae pyogenic liver abscess (KPPLA). The existing data are heterogeneous and the actual disease burden and risk factors for the development of EE among patients with KPPLA have not been systematically examined. We performed a systematic review and meta-analysis to examine the incidence of EE, temporal trend of EE, and risk factors for EE in patients with KPPLA.

METHODOLOGY

The MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched for articles published from inception to 2020 that evaluated the incidence of EE among patients with KPPLA. By a random-effects method, a pooled estimate of its incidence with 95% confidence intervals was estimated along with examination of its temporal and geographic variations. Pooled odds ratios were calculated for risk factors.

RESULTS

Fifteen retrospective studies reporting data on 11889 patients with KPPLA met the inclusion criteria and were analyzed. With 217 patients developing EE, the pooled incidence of EE was 4.5% (95% confidence interval 2.4% to 8.2%). The heterogeneity was considerable and significant (Cochran's Q 243.5, p < 0.001, I² = 94.2%).

CONCLUSION

This meta-analysis estimates the actual incidence of EE among patients with KPPLA, where EE is reported in about 1 of 22 patients with KPPLA. Infection caused by K1 capsular serotype was an independent risk factor.

Pyogenic liver abscess and endogenous endophthalmitis secondary toKlebsiella pneumoniae

Invasive Liver Abscess Syndrome is a manifestation of systemic infection caused by Klebsiella pneumoniae. This constellation of symptoms has been well-reported throughout Southeast Asia though it is uncommon in the United States. This article reports the identification of a pyogenic liver abscess and associated endogenous endophthalmitis in a patient presenting to the emergency department.

A retrospective study of pyogenic liver abscess caused primarily by Klebsiella pneumoniae vs. non-Klebsiella pneumoniae: CT and clinical differentiation

PURPOSE

The incidence of Klebsiella pneumoniae pyogenic liver abscesses (KP-PLA) is increasing. However, its diagnosis and treatment are often delayed, leading to complications. In this study, we aimed to retrospectively compare computed tomographic (CT) features of KP-PLAs with those of abscesses caused by other bacterial pathogens (non-KP-PLAS) and to further identify prognostic factors for PLA.

METHODS

Data of 219 study patients including clinical presentation, comorbid conditions, metastatic infection, treatment duration, and mortality were retrospectively collated. CT characteristics of abscesses were recorded. Etiology was established by pus and/or blood culture. The differentiating CT features and clinical findings were compared between the monomicrobial KP-PLA and non-KP-PLA groups. Furthermore, factors related to in-hospital case fatality were analyzed.

RESULTS

Multivariate analysis identified thin-walled abscesses, absent rim enhancement, metastatic infection, and absence of underlying biliary tract disease as significant predictors of KP-PLA. With 3/4 criteria applied in combination, a specificity of 96.5% was achieved for KP-PLA diagnosis. The in-hospital mortality rate was 3.7%. Multivariate analysis revealed that diabetes mellitus (P = 0.031), multiple abscesses (P = 0.026), internal gas bubble (P = 0.041), metastatic infection (P = 0.004), and septic shock (P = 0.002) were significantly associated with mortality.

CONCLUSION

Thin-walled abscess, metastatic infection, absence of rim enhancement, and absence of underlying biliary tract disease are potentially useful CT findings for early KP-PLA diagnosis.

A rare case of massive pericardial effusion due to spontaneous rupture of Streptococcus anginosus group liver abscess

Purulent pericardial effusion is a rare and life-threatening complication of pyogenic liver abscess if not diagnosed and intervened early. Due to its nonspecific presentation, diagnosis of pyogenic liver abscess is challenging. Herein, we discuss the case of a 31-year-old healthy male that presented with acute chest tightness for one day in the setting of spontaneous rupture of pyogenic liver abscess and developed transdiaphragmatic extension of purulent pericardial effusion. The abscess resolved with antibiotic therapy (beta-lactam), ultrasound-guided aspiration, and pericardial window. Culture of pericardial fluid yielded the Streptococcus anginosus group. He was subsequently discharged following clinical resolution and normalization of liver function tests after 15 days of treatment. Follow-up ultrasonography revealed that the liver abscess and pericardial effusion were resolved in 8 weeks post treatment and intervention.

Percutaneous fine-needle aspiration for pyogenic liver abscess (3-6 cm): a two-center retrospective study

BACKGROUND

The role of ultrasonography-guided percutaneous fine-needle aspiration (PNA) for pyogenic liver abscess (PLA) remains without consensus, especially in abscesses 3 to 6 cm in diameter. The objective of this study was to evaluate the comparative effectiveness and safety of PNA combined with antibiotics.

METHODS

This was a retrospective study of patients with PLA that were from 3 to 6 cm in diameter who treated at two medical centers in Shanghai, China, from January 2014 to March 2019. Patients were divided into groups treated by PNA plus antibiotics or antibiotics alone. Patients demographics and clinical data related diagnosis, antibiotic treatment, and patient outcomes were analyzed.

RESULTS

Out of a total of 94 PLA patients, 42 (44.7%) patients received PNA combined with antibiotics, and 52 (55.3%) received antibiotics alone. There were no complications related to PNA. In the PNA group, 13 (31.7%) patients with negative blood culture and 8 (19.5%) patients without blood culture were microbiologically confirmed via aspiration. The time for temperature normalization (P < 0.001) and the reduction rate of C-reactive protein within the first week (P = 0.031) were significantly lower in the PNA group. In the multivariate analysis, treatment with PNA was more likely to result in clinical improvement of PLA (odds ratio = 0.33, 95% confidence intervals (CI): 0.11-0.96, P = 0.043).

CONCLUSIONS

PNA combined with antibiotics appears to be a safe, effective, and promising treatment for PLA of 3-6 cm in size. Furthermore, the technique allows for direct microbial sample, which can improve the selection of antibiotics.

Cryptogenic Pyogenic Liver Abscess Due to Fusobacterium nucleatum in an Immunocompetent Patient

In this case, a 76-year-old female presented with 3-4 days of fever with no other localizing signs. Notably, she had had an untreated Fusobacterium bacteraemia approximately 8 weeks prior to admission. She underwent abdominal imaging which demonstrated a liver abscess and had percutaneous drainage of the same. Blood and pus cultures both grew Fusobacterium nucleatum, which is an unusual organism to be associated with a liver abscess, especially in an immunocompetent host with no risk factors for this condition. Interestingly, this patient did not have any history of dental work, instrumentation, liver function test (LFT) abnormalities and no extrahepatic source for the abscess. This case highlights the importance of having a high index of clinical suspicion for an occult source of infection and emphasizes the importance of following up on cultures even after discharge of a patient, since anaerobic infections such as those caused by Fusobacterium can have a largely indolent course.

LEARNING POINTS

Fever of unknown aetiology with prior bacteraemia merits a thorough work-up for occult sources such as a localized abscess or malignancy, which can cause bacterial translocation.Fusobacterium and other anaerobic infectious agents should be considered in the context of an indolent disease course since they are slow-growing in cultures, and also, if the patient has risk factors such as immunosuppression, diabetes, poor oral hygiene and so on.It is important to have systems in place in hospitals to ensure follow-up for patients who may have a positive culture after discharge from hospital to confirm that the infection is adequately addressed.

Gastric cancer and adenomatous colorectal polyp concomitant with pyogenic liver abscess and bacteremia

Synchronous gastric cancer and adenomatous colorectal polyp in patients with Klebsiella pneumoniae-induced pyogenic liver abscess (KP-PLA) and bacteremia is a rare presentation. A 58-year-old man with a 6-month history of diabetes mellitus (DM) presented with febrile sensation and dull abdominal pain in the right upper quadrant of the abdomen. Subsequent to laboratory test results and abdominal computed tomography findings, KP-PLA with bacteremia was diagnosed. After intravenous antibiotic administration, his symptoms improved, and upper endoscopy and colonoscopy were performed to evaluate the cause of KP-PLA. Biopsy specimens of the prepyloric anterior wall revealed a moderately differentiated adenocarcinoma. Endoscopic mucosal resection of the colon revealed high-grade dysplasia. Early gastric cancer (EGC) and adenomatous colorectal polyps with high-grade dysplasia concomitant with KP-PLA and bacteremia were diagnosed in our patient who had DM. Intravenous antibiotic treatment for KP-PLA, subtotal gastrectomy for EGC, and colonoscopic mucosal resection for the colon polyp were performed. After 25 days of hospitalization, subtotal gastrectomy with adjacent lymph node dissection was performed. Follow-up ultrasound imaging showed resolution of the abscess 5 weeks post-antibiotic treatment, as well as no tumor metastasis. Upper gastrointestinal endoscopy and colonoscopy should be performed to evaluate gastric cancer in patients with PLA or bacteremia, accompanied with DM or an immunocompromised condition.

Raoultella ornithinolytica and Klebsiella oxytoca pyogenic liver abscess presenting as chronic cough

Raoultella ornithinolytica is a Gram-negative rod belonging to the Enterobacteriaceae family and closely related to Klebsiella spp. It is commonly present in aquatic environments. Human infections caused by R. ornithinolytica are being increasingly recognized. It has been documented to cause various hospital-acquired infections including but not limited to gastrointestinal, skin, and genitourinary infections. The organism has been particularly associated with invasive procedures and is commonly seen in patients with malignancy, diabetes, chronic kidney disease and immunodeficiency. To our knowledge, we report the first case of pyogenic liver abscess caused by this organism. The patient presented subtly with a chronic, nonresolving cough and was managed successfully by surgical drainage and appropriate antimicrobials.

Effect of diabetes mellitus on short-term prognosis of 227 pyogenic liver abscess patients after hospitalization

BACKGROUND

Pyogenic liver abscess (PLA) is an inflammatory disease with increasing incidence. When it occurs with diabetes mellitus (DM), the risk of recurrence and mortality may increase. However, the effect of DM on the short-term prognosis of PLA patients after hospitalization remained unknown.

METHODS

Two hundred twenty-seven PLA patients who received treatment at the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to January 2018 were retrospectively enrolled. They were divided into two groups as the DM group (n = 61) and the Non-DM group (n = 166). In the DM group, HbA1C level < 7% was considered to be good-control of glycaemia (n = 23). The clinical characteristics and overall short-term survival were analyzed.

RESULTS

The proportion of PLA patients with DM was 26.87%. In the DM group, there was a higher incidence of hypertension and Candida spp. infection. Conservative administration and percutaneous drainage were mainly used in patients with good- (60.87%) and poor-control (60.53%) of glycaemia, respectively. During follow-up, 24 (10.57%) died due to uncontrolled systemic infections and other serious complications. Compared with PLA patients without DM, patients in the DM group had significantly increased 6-month mortality rate after discharge (Log-Rank test, P = 0.021). Poor-control of glycaemia did not reduce the six-month survival, while the recurrence rate of PLA within 3 months showed an almost 3-fold increase (13.16% vs. 4.35%). Further multivariate analyses found that DM was the only independent risk factor for the PLA six-month survival (odds ratio [OR]: 3.019, 95% confidence interval [CI]: 1.138-8.010, P = 0.026). However, the blood glucose level had no significant effect on the short-term survival of PLA patients with DM (Log-Rank test, P = 0.218).

CONCLUSIONS

In PLA patients, DM aggravated short-term mortality and blood glucose levels should be well controlled.

Serum amyloid A levels in patients with liver diseases

BACKGROUND

Serum amyloid A (SAA) is an acute phase protein mainly synthesized by the liver. SAA induces inflammatory phenotype and promotes cell proliferation in activated hepatic stellate cells, the major scar forming cells in the liver. However, few studies have reported on the serum levels of SAA in human liver disease and its clinical significance in various liver diseases.

AIM

To investigate the serum levels of SAA in patients with different liver diseases and analyze the factors associated with the alteration of SAA levels in chronic hepatitis B (CHB) patients.

METHODS

Two hundred and seventy-eight patients with different liver diseases and 117 healthy controls were included in this study. The patients included 205 with CHB, 22 with active autoimmune liver disease (AILD), 21 with nonalcoholic steatohepatitis (NASH), 14 with drug-induced liver injury (DILI), and 16 with pyogenic liver abscess. Serum levels of SAA and other clinical parameters were collected for the analysis of the factors associated with SAA level. Mann-Whitney U test was used to compare the serum SAA levels of patients with various liver diseases with those of healthy controls. Bonferroni test was applied for post hoc comparisons to control the probability of type 1 error (alpha = 0.05/6 = 0.008). For statistical tests of other variables, P < 0.05 was considered statistically significant. Statistically significant factors determined by single factor analysis were further analyzed by binary multivariate logistic regression analysis.

RESULTS

All patients with active liver diseases had higher serum SAA levels than healthy controls and the inactive CHB patients, with the highest SAA level found in patients with pyogenic liver abscess (398.4 ± 246.8 mg/L). Patients with active AILD (19.73 ± 24.81 mg/L) or DILI (8.036 ± 5.685 mg/L) showed higher SAA levels than those with active CHB (6.621 ± 6.776 mg/L) and NASH (6.624 ± 4.891 mg/L). Single (P < 0.001) and multivariate logistic regression analyses (P = 0.039) for the CHB patients suggested that patients with active CHB were associated with an SAA serum level higher than 6.4 mg/L. Serum levels of SAA and CRP (C-reactive protein) were positively correlated in patients with CHB (P < 0.001), pyogenic liver abscess (P = 0.045), and active AILD (P = 0.02). Serum levels of SAA (0.80-871.0 mg/L) had a broader fluctuation range than CRP (0.30-271.3 mg/L).

CONCLUSION

Serum level of SAA is a sensitive biomarker for inflammatory activity of pyogenic liver abscess. It may also be a weak marker reflecting milder inflammatory status in the liver of patients with CHB and other active liver diseases.

Clinical, microbiological, and molecular epidemiological characteristics of Klebsiella pneumoniae-induced pyogenic liver abscess in southeastern China

Background

Klebsiella pneumoniae-induced pyogenic liver abscess (KP-PLA) has emerged as a life-threatening disease worldwide. However, to date, a limited number of scholars have attempted to systematically elucidate the characteristics of KP-PLA. The aim of the present study was to analyze clinical, microbiological, and molecular epidemiological characteristics of KP-PLA patients in Southeastern China.

Methods

The KP-PLA cases from a tertiary teaching hospital in China from January 2016 to December 2017 were systemically studied and elucidated comprehensively. The virulence factors, resistant spectrum, and clones of K. pneumoniae isolates were identified with string test, polymerase chain reaction (PCR), antimicrobial susceptibility test, and multilocus sequence typing. Moreover, the characteristics in KP-PLA patients with and without other hepatobiliary diseases (OHD) were also been compared.

Results

A total of 163 KP-PLA cases were enrolled, in which the majority of those cases were senior males, and often associated with multiple underlying diseases, including diabetes (49.7%). The remaining cases belonged to healthy individuals (50.3%). The clinical symptoms were common but nonspecific, characterized by increased inflammatory parameters and abnormal liver function parameters. The abscess was often right-sided solitary presentation (58.3%). Cephalosporin or carbapenem plus metronidazole combined with percutaneous puncture or catheter drainage were favorable therapeutics. Although low resistance rates of commonly used antimicrobial drugs (< 10%) were observed, twelve strains were identified as multidrug resistant (MDR) strains, and were mainly isolated from the OHD patients. The hypermucoviscosity, as well as K1 and K2 serotypes accounted for 30.7, 40.5, and 19.0%, respectively. Except for iroN (24.5%) and magA (45.4%), the high prevalence of virulence genes (e.g. aerobactin, rmpA, mrkD, fimH, uge, ureA, entB, ybtA, kfuBC, and wcaG) was identified (68.7–100.0%). Additionally, ST23 was found as a predominant sequence type (ST; 38.7%), and three novel STs (ST3507, ST3508 and ST3509) were noted as well.

Conclusions

The present study reported the abundant hvKp strains in KP-PLA, as well as convergence of hypervirulent and MDR K. pneumoniae isolates from the KP-PLA patients, particularly those cases with OHD. Given the various clinical manifestations and destructive pathogenicity, determination of the comprehensive characteristics of such isolates is highly essential to effectively carry out for optimal management and treatment of KP-PLA.

Pyogenic liver abscesses concomitant with advanced gastric cancer: a case report

It has been reported that gastric cancer rarely causes pyogenic liver abscesses because of its mucosal acid barrier. Herein, we describe a rare case of pyogenic liver abscesses concomitant with advanced gastric cancer. A 61-year-old man was transferred to our hospital with persistent nausea and fever. Computed tomography showed a lobulated lesion in the caudate lobe of the liver, slightly rim-enhanced lesions in the right lobe, enhanced mass on the lesser curvature of the upper gastric body, and enlarged regional lymph nodes. Subsequent upper gastrointestinal endoscopy revealed a type 3 tumor on the lesser curvature of the upper gastric body; pathological examination of a biopsy showed adenocarcinoma. After treatment with antibiotics, the lesion in the caudate lobe decreased in size and the enhanced lesions in the right lobe resolved. The patient underwent curative gastrectomy; the pathological diagnosis was gastric cancer, T4aN3aM0 stage IIIB, according to the Japanese classification of gastric carcinoma (Third English edition). The patient was discharged without complications and underwent adjuvant chemotherapy. Gastric cancer can cause pyogenic liver abscesses. Although differentiating between liver abscesses and hepatic metastases can be difficult, multidisciplinary and appropriate treatment strategies are needed.

Clinical characteristics and treatment outcomes in a cohort of patients with pyogenic and amoebic liver abscess

Background

We describe the clinical features of a cohort of patients with liver abscesses and investigate relationships between clinical, radiological and microbiological findings and mortality.

Methods

Retrospective review of pyogenic (PLA) or amoebic liver abscesses (ALA) diagnosed and treated at a major infectious diseases department in London over 9 years.

Results

One hundred forty-one patient records were identified; 132 (93.6%) had PLA and 9 (6.4%) ALA. No organism was identified in 38.6% (51/132); a single bacterial species was isolated in 47.0% (62/132) of PLA, ≥ 2 in 14.4% (19/132). There was weak evidence of variation in abscess size by type of microorganism, with streptococcal PLA typically larger (p = 0.03 for Streptococcus milleri group, p = 0.05 for non-milleri streptococci). Patients with ALA were younger (median 41, IQR 37–51 years) than those with PLA (median 68, IQR 50.5–78 years) (p = 0.003) and all were male (9/9, 100%, (p = 0.03)), with a history of recent travel in the majority (6/9, 66.7% (p = 0.003)). C-reactive protein was higher in ALA than in PLA (p = 0.06). In the entire cohort, loculation (HR = 2.51 (95% CI 1.00–6.32), p = 0.04) and baseline ALP (HR = 4.78 (95% CI 1.19–19.2) per log₁₀ increase, p = 0.03) were associated with mortality. 16S ribosomal RNA (rRNA) analysis was used in a subset of culture-negative cases and increased the diagnostic yield by 13%.

Conclusions

Clinical or radiological features cannot be used to distinguish between PLA and ALA, or help identify the bacterial cause of PLA. However, ALA is more common in young, male patients with a history of travel. 16S rRNA analysis of abscess fluid has a role in improving microbiological diagnosis in culture-negative cases.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4127-8) contains supplementary material, which is available to authorized users.