Pyogenic and amebic liver abscesses

Profile of Amoebic vs Pyogenic Liver Abscess and Comparison of Demographical, Clinical, and Laboratory Profiles of these Patients From a Tertiary Care Center in Northern India

Background and objective

Amoebic liver abscess (ALA) and pyogenic liver abscesses (PLA) are the most common causes of liver abscess in developing and developed countries, respectively. Although incidence of liver abscess is low, but mortality is high amongst the patients due to delayed diagnosis. The study was done to find out the prevalence of amoebic and PLA among patients of liver abscess. The clinical, personal, and demographical details were also evaluated to find out the risk factor(s) associated with ALA and PLA, respectively.

Method

A retrospective study was conducted to find the prevalence of amoebic and PLA. Clinical, demographic, personal details were evaluated from hospital records. Laboratory parameters such as total leucocyte count, platelets, bilirubin, ESR (Erythrocyte Sedimentation Rate), hemoglobin, glycosylated hemoglobin (HbA1c), alkaline phosphate (ALP), Aspartate aminotransferase (SGOT/AST), Alanine aminotransferase (SGPT/ALT), serum albumin, bilirubin levels, and procalcitonin were recorded. The Ultrasonography (USG) findings regarding the size, location, volume, and number of abscesses were also analyzed.

Results

Total of 107 patients of liver abscess were evaluated, and 61.6% of patients were of amoebic etiology, and 25.3% were of pyogenic etiology. Males of 20-60 years of age were predominantly affected with right upper quadrant pain and fever as the most common presentations. ALA patients were found to have solitary abscess in the right lobe involving 6th and 7th segments, with decreased hemoglobin, hyperbilirubinemia, elevated ALP and SGOT, with normal SGPT, and addiction to alcohol. PLA patients had increased HbA1c, increased PCT values, low serum albumin levels, and low platelet-to-white blood cell values. The most common bacteria causing PLA was Escherichia coli (n = 8) followed by Enterobacter cloacae (n = 5). Mortality was seen in 6 patients.

Conclusion

Liver abscess is found to have relatively high mortality and morbidity. Therefore, early diagnosis is the only method to prevent mortality and morbidity in these patients. Since the presentation is very nonspecific, evaluation of certain risk factors and laboratory parameters can aid in the diagnosis.

Increasing incidence of pyogenic liver abscess in Southern Sweden: a population-based study from 2011 to 2020

BACKGROUND

Pyogenic liver abscess (PLA) is a rare but potentially life-threatening disease, and estimates suggest a gradual increase in the incidence during the last decades. The primary aim of this study was to report the incidence, trend and aetiology of PLA during a decade in Southern Sweden.

METHODS

This was a population-based observational cohort study between 2011 and 2020 in Skåne, Southern Sweden. Data were retrieved from the Swedish National Board of Health and Welfare for all individuals diagnosed with liver abscess (K750) according to ICD-10 (International Statistical Classification of Diseases, 10th revision).

RESULTS

A total of 456 episodes of PLA occurred in 364 patients during the study period. The median age of the first PLA episode was 71 years (range 3-97) and 57% (n = 206) were men. The mean incidence of all patients was 3.4/100,000 person-years (range 1.8-5.2). The incidence increased almost three times, from 1.8/100,000 person-years in 2011 to 5.2/100,000 person-years in 2020. Streptococcus species, Escherichia coli and Klebsiella species accounted for the vast majority of both mono- and polymicrobial findings in both blood and local abscess cultures. 16s rDNA added information about aetiology in 37% of episodes.

CONCLUSION

The incidence of PLA increased during the study period, and Streptococcus spp., Klebsiella spp. and E. coli dominated both blood and local cultures. Despite antimicrobial therapy, pathogens could be found in local abscess cultures several weeks into treatment. Increased use of 16s rDNA in the management of PLA could be beneficial.

A Case of Amoebic Liver Abscess Presenting as a Therapeutic Conundrum Necessitating the Exploration of Other Under-the-Radar Treatment Modalities

Tropical countries have recorded incidences of amoebic liver abscess (ALA) owing to the more significant epidemiology and pathogenicity of the intestinal protozoan Entamoeba histolytica in these regions. However, the rise in the number of immigrants from such areas to developed countries has made it necessary to thoroughly review the diseases caused by the parasite globally. Patients generally present with the usual features of right upper quadrant pain, painful hepatomegaly, mild jaundice, and vomiting, to name a few; however, the condition can manifest varied presentations accompanied by a plethora of findings non-responsive to the standard treatment. Therefore, newer modalities should be considered by weighing their risks and benefits to reduce morbidity and mortality and improve patient outcomes.

Efficacy of laparoscopic surgery in the treatment of hepatic abscess: A systematic review and meta-analysis

Background

Liver abscess is a common cause of intra-abdominal infection and its treatment depends on the presentation. Laparoscopy, in addition to its classic benefits, has particular advantages in the management of liver abscess but its role is not well defined and studies done in that field are heterogenous. The objective of this systematic review is to evaluate the efficacy of laparoscopic surgery in the management of liver abscess.

Methods

We realized a systematic review and meta-analysis including studies published in the 20 last years. The primary outcome was the pooled prevalence of recurrent or residual liver abscess after laparoscopic treatment.

Results

We retrieved 190 studies regarding laparoscopic surgery in liver abscess and 17 studies were included in the quantitative and qualitative synthesis. A total of 608 patients was included and 299 of them (49.1%) were treated by laparoscopic surgery. The indications were mainly failure of first line treatment (antibiotic treatment and/or percutaneous drainage and/or needle aspiration) and ruptured multiloculated, or caudate lobe liver abscess. The surgical gesture performed was laparoscopic drainage in all studies. The post-operative rate of recurrent or residual liver abscess after treatment by laparoscopy was 4.22% (95% CI: 2.29–7.07).

Conclusions

This systematic review showed that laparoscopic drainage had a considerable place in the management. The post-operative rate of recurrence was low with no mortality suggesting that laparoscopy is safe and feasible for liver abscess management.

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Surgery in the treatment for liver abscess has its indications limited to ruptured liver abscess, particularly in the peritoneal cavity.

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Laparoscopy can be used both for unruptured and ruptured liver abscess when there are failure or contraindications of percutaneous drainage.

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This review suggest the safety and feasibility of laparoscopy with a low rate of post-operative recurrent or residual liver abscess.

Amoebic Liver Abscess: Rare Entity in Recent Times

Intestinal amoebiasis and sequelae such as amoebic liver abscess are rarely reported in the era of modern medicine. Atypical presentation of amoebic liver abscess with high false-positive results on serology in endemic regions poses major diagnostic issues in the developing nations of the world. We report a case of amoebic liver abscess and describe the imaging appearances in a 59-year-old female. A detailed medical history was elicited to determine the etiology of amoebic liver abscess. Furthermore, the diagnosis was confirmed based on serological tests. Percutaneous aspiration of the amoebic liver abscess was performed, and treatment was initiated with intravenous metronidazole followed by diloxanide furoate. The patient has been on follow-up since three months with a negative stool examination and with no complaints of recurrence.

CT of amebic liver abscess: different morphological types with different clinical features

Purpose

To identify different morphological types of amebic liver abscess (ALA) based on CT findings and to assess whether they have different clinical features.

Method

CT images of 112 symptomatic patients with ALA were analyzed to identify the imaging features distinctive of each morphological type. The following CT findings were investigated: the presence of abscess wall, rim enhancement, edge characteristic, septa, intermediate density zone, and peripheral hypodensity. Abscesses from each type were further evaluated for their clinical presentations, laboratory findings and outcomes.

Results

We identified three types of ALAs: type I, II and III. Type I abscesses (66%) were characterized by absent or incomplete walls, ragged edges and peripheral septa; their edges exhibited irregular and interrupted enhancement. Type II (28%) had a complete wall characterized by rim enhancement and peripheral hypodense halo. Type III (6%) demonstrated a wall but without enhancement. Clinically, type I abscesses presented acutely with severe disease. They had significantly deranged laboratory parameters, higher incidence of rupture and higher rate of inpatient or intensive care unit admission. The severity of the disease prompted immediate percutaneous drainage in most type I abscesses (81%). Two of them died from multiple organ failure. The type II or III abscesses, on the other hand, had delayed presentations with mild to moderate disease, with near normal laboratory findings.

Conclusion

ALAs have three different CT morphological types, with different clinical and laboratory features. Percutaneous drainage is indicated in most of type I abscesses.

Typical imaging finding of hepatic infections: a pictorial essay

Hepatic infections are frequent in clinical practice. Although epidemiological, clinical and laboratory data may suggest hepatic infection in certain cases, imaging is nearly always necessary to confirm the diagnosis, assess disease extension and its complications, evaluate the response to treatment, and sometimes to make differential diagnoses such as malignancies. Ultrasound (US) is usually the first-line investigation, while computed tomography (CT) and magnetic resonance imaging (MRI) provide better characterization and a more precise assessment of local extension, especially biliary and vascular. The purpose of this article is to describe the typical features and main complications of common hepatic infections. Familiarity with the radiological features of this entity can help suggest the correct diagnosis and the need for further studies as well as determine appropriate and timely treatment.

A rare hepatic mass in an Italian resident

Background

Amebiasis is a rare condition in developed countries but epidemiologically growing. Clinical manifestation may range from asymptomatic to invasive disease, amoebic liver abscess being the most common manifestation. We report a peculiar case of left hepatic amoebic liver abscess in a patient without a well-known source of infection and presenting with left portal vein thrombosis.

Case presentation

Patient, working as longshoreman, presented with complaints of remittent-intermittent fever lasting from 2 weeks. Physical examination was normal. Blood tests showed mild anemia, neutrophilic leukocytosis and elevated inflammation markers. Chest x-rays was normal. Abdominal ultrasound showed multiple hypoechoic liver masses. CT-scan of abdomen showed enlarged left liver lobe due to the presence of large abscess cavity along with thrombosis of left portal vein. The indirect hemagglutination test for the detection of antibodies to Entamoeba histolytica (Eh) was positive. Ultrasound-guided percutaneous drainage revealed “anchovy sauce” pus. Metronidazole and a follow up imaging at 3 months showed resolution of abscess cavity.

Conclusion

This case shows that amoebic liver abscess is possible even in first world country patients without travel history. Left sided abscess and portal vein thrombosis are rare and hence reported.

Clinical Characteristics and Treatment Outcomes in Human Immunodeficiency Virus (HIV)-Infected Patients with Liver Abscess: A Retrospective Study of 53 Patients

BACKGROUND Although episodes of liver abscess (LA) have been reported in patients infected with the human immunodeficiency virus (HIV), specific symptoms in these patients remain unclear. MATERIAL AND METHODS The clinical characteristics, laboratory findings, treatments, and final clinical outcomes of LA in 53 HIV-infected patients were analyzed. RESULTS The most common clinical manifestations were fever (92.5%), chills (41.5%), and abdominal pain (37.7%). The mean CD4⁺ T cell count in these HIV-infected patients at admission was 328.09±236.192 cells/µL. LA and blood cultures were positive in six (17.6%) and two (5.4%) patients, respectively. Thirteen strains of pathogens, including Staphylococcus, Corynebacterium, and Candida, were detected in LA cultures. Forty-four (95.7%) of 46 patients were successfully treated with antibiotics plus image-guided percutaneous aspiration, drainage, or surgery, whereas four (57.1%) of the remaining seven patients were successfully treated with antibiotics alone. Septic shock [odds ratio (OR)=8.970; 95% confidence interval (CI)=0.840-92.110; p=0.014] and ascites (OR=7.057; 95% CI=0.683-72.957; p=0.016) were found to be independent risk factors for poor prognosis. The clinical characteristics of LA in HIV-infected patients were nonspecific, with bacteria being the primary pathogens. CONCLUSIONS Antibiotics plus image-guided percutaneous drainage can effectively improve treatment outcomes in HIV-infected patients with LA.

Streptococcus mitis Abscesses Mimicking Liver Metastases

Streptococcus mitis (S. mitis) is a commensal bacterial species that commonly colonizes the oropharynx and gastrointestinal tract. It is seldom reported as a human pathogen. However, immunocompromised individuals may be at risk of infection. We describe a 62-year-old male with prostate cancer who presented with multiple S. mitis abscesses masquerading as metastases. In addition, we discuss the differential diagnosis and treatment options for this rare opportunistic infection.

Pyogenic and Amebic Infections of the Liver

Pyogenic liver abscesses are classified by the bacteria that have caused the abscess because this guides treatment and can point to the underlying cause. The most common cause is biliary disease. The diagnosis is made by imaging. Treatment is a combination of antibiotics and percutaneous drainage. Amebic liver abscess is caused by extraintestinal spread of Entamoeba histolytica. E histolytica is spread by fecal-oral transmission and typically colonizes the gastrointestinal tract. It is diagnosed based on imaging and the mainstay of treatment is metronidazole. Only about 15% of cases require percutaneous drainage. The prognosis is good, with almost universal recovery.

Bacterial Superinfection of Amoebic Liver Abscess

A 78-year-old male, originally from China, was brought to the hospital for weakness, urinary incontinence, confusion, and poor oral intake. He was started on empiric antibiotics, which were narrowed when blood cultures produced gram-negative bacteremia speciating to Klebsiella pneumoniae, sensitive to ceftriaxone. Computed tomography scan of the abdomen and pelvis demonstrated a large cystic region with air-fluid level in the left lobe of the liver. Suspecting this to be the source of the patient's bacteremia, the lesion was percutaneously drained and the fluid cultured, which also revealed ceftriaxone-sensitive Klebsiella pneumoniae. While a stool ova and parasite examination on the patient was negative, further workup was positive for Entamoeba histolytica antibody in the serum, detected via enzyme-linked immunosorbent assay and indicative of either current or past infection. This suggested possible prolonged subclinical infection with bacterial superinfection, especially given that Klebsiella pneumoniae is one of the most common organisms cultured from these abscesses. In patients with liver abscesses who immigrated from developing and/or endemic regions or have a relevant recent travel history, an underlying amoebic etiology of an abscess should be considered.

Study of ultrasound-guided needle aspiration and catheter drainage in the management of liver abscesses

PURPOSE

To evaluate and compare the efficacy of intermittent needle aspiration and continuous catheter drainage in ultrasound-guided management of liver abscesses.

METHODS

This was a prospective, randomised study conducted on 100 patients (88 males and 12 females; age range 22-74 years) with liver abscess(es) and having abscess size more than 5 cm, divided into two groups: Percutaneous needle aspiration (PNA) (n = 50) and percutaneous catheter drainage (PCD) (n = 50). Criteria of exclusion were: rupture of abscess before intervention; prior intervention; uncorrectable coagulopathy; concomitant biliary tract malignancy. In the PNA group, pus was aspirated by an 18-gauge needle using freehand technique and the number of aspirations was limited to two. Failure of abscess size to decline below 50% of the original diameter or of clinical improvement after second aspiration was considered as failure of aspiration. In the PCD group, drainage was done by 12-French catheters using Seldinger technique. Drainage was considered as failure if abscess cavity did not resolve and laparotomy was needed to evacuate the pus cavity.

RESULT

The success rate in the PNA group was 88% and 92% in the PCD group; however, this difference was statistically not significant, suggesting that both are equally efficacious. The total duration of hospital stay (mean 6.8 days [PNA] vs 10.5 days [PCD]; p value: 0.011) and the average duration between intervention and discharge (5.9 days [PNA] vs 10.2 days [PCD]; p value:0.026) were significantly less in the PNA group. One major complication was seen in our study: peritonitis due to peri-catheter leak in PCD group.

CONCLUSION

Both procedures are equally efficacious in the management of liver abscesses; however in view of less duration of hospital stay, patient safety and comfort, procedure simplicity, and the reduced cost, needle aspiration should be used as the first-line procedure in the treatment of liver abscess (even in abscesses more than 5 cm). Catheter drainage should be reserved for cases that do not respond to a second attempt of aspiration.

Hepatic Abscess in a Returning Traveler with Crohn's Disease: Differentiating Amebic from Pyogenic Liver Abscess

Liver abscess is a rare but serious complication of Crohn's disease. Patients with Crohn's disease are at risk for pyogenic liver abscesses due to immunosuppressive therapy, fistulous disease, and intraabdominal abscesses. Inflammatory bowel disease patients are also known to have a greater prevalence of amebiasis compared to the rest of the population; however, a higher incidence of amebic liver abscess has not been reported. We describe a case of a liver abscess in a patient with Crohn's disease that was initially presumed pyogenic but later determined to be amebic in origin. Epidemiology, clinical presentation, diagnosis, and treatment of amebic and pyogenic liver abscesses are discussed.

Clostridium tertium: An Unusual Cause of Pyogenic Liver Abscess

Pyogenic liver abscess (PLA) is the result of portal vein pyemia, which usually originates from the hepatobiliary system or the gastrointestinal tract. Gram-negative organisms are the most common causative pathogens in PLA. Clostridium tertium is an anaerobic gram-positive, low-virulence organism that most commonly affects neutropenic patients with hematological malignancy and has not been reported to cause PLA. We report an unusual presentation of a C. tertium infection as a PLA in a previously healthy, immunocompetent patient with no identifiable source of portal pyemia.

Septic Shock in the Course of Liver Absces Rescued with Percutaneous Drainage - A Literature Review and Case Report

This study presented a septic shock occurring with striking speed during the percutaneous drainage of a large abscess of the liver in an 18-year-old female patient after an appendectomy performed 3 months earlier using the laparoscopic method because of its phlegmonous and gangraenosus inflammation. The post-operative course was complicated by increased suppuration in places after removal of the trocars. After including the intravenous antibiotic therapy and under the USG control, the percutaneous drainage of the abscess was performed. While withdrawing the guide of the drainage catheter set, the symptoms of septic shock occurred. The pharmacological treatment was applied with continuation of the antibiotic therapy till a negative result of microbiological tests was obtained and the normalization of life parameters. The patient was not qualified for treatment in the ICU. She was discharged in a generally good condition after 24 days of hospitalization. In the case of this patient, the drain covered with the content of the abscess may have contact with the adjacent tiny blood vessels, which may have contributed to the systemic inflammatory response syndrome that was linked with fast-developing sceptic shock.

[Liver abscess]

Liver abscess is a rare and severe infection. Incidence increases because of aging of population, advances in liver and biliary surgery including liver transplantation, and immunodeficiency factors. Diagnosis depends mainly on imaging and needle aspiration for microbiological identification. Treatment is based on antibiotics, percutaneous or surgical drainage, and control of the primary source.

Multiple Amoebic Liver Abscess As Initial Manifestation in Hiv Sero-Positive Male

Amoebic liver abscess is the most frequent extra-intestinal manifestation of Entamoeba histolytica infection. Immunosuppression is known to predispose to amoebic liver abscess. Although amoebic liver abscess is seen more commonly in patients of Human-Immunodeficiency virus (HIV), first presentation of HIV sero-positive patient as multiple liver abscess is quite uncommon.The author reports an unusual case of multiple liver abscesses in an HIV seropositive patient. This middle aged male with history of multiple unprotected sexual encounters presented with spasmodic abdominal pain, fever, diarrhoea and weight loss along with generalised ill-health and painful liver enlargement. HIV-1 serology was found to be reactive. Imaging revealed an enlarged liver with multiple, irregular, hypoechoic foci characteristic of abscesses. Amoebic aetiology was later confirmed by percutaneous aspiration and microscopy. Administration of appropriate chemotherapeutics along with institution of antiretroviral therapy led to both clinical resolution as well as disappearance of lesions.

[Drainage of amoebic liver abscess by single incision laparoscopic surgery. Report of a case]

BACKGROUND

Single incision laparoscopic surgery has increased recently due to successful results, achieved in several procedures. The aim of the present work is to present the first case in which single incision laparoscopy is used for the drainage of an amoebic liver abscess.

CLINICAL CASE

A 44-year-old man presented with intense right upper quadrant pain, generalised jaundice, tachycardia, fever, hepatomegaly and a positive Murphy's sign. Laboratory results revealed an increased plasma bilirubin, elevated alkaline phosphatase and transaminases, leucocytosis, negative viral panel for hepatitis, and positive antibodies against Entamoeba histolytica. On an abdominal computed tomography a 15 × 12.1 cm hypodense lesion was observed in the patient's liver, identified as an amoebic liver abscess. Analgesics and antibiotics were started and subsequently the patient was submitted to laparoscopic drainage of the abscess using a single port approach. Drainage and irrigation of the abscess was performed. Four days later the patient was discharged without complications.

CONCLUSION

Management of amoebic liver abscess is focused on the elimination of the infectious agent and obliteration of the abscess cavity in order to prevent its complications, especially rupture. Laparoscopic surgery has proved to be a safe and effective way to manage this entity.

Faecolith migrating from the appendix to produce liver abscess after subhepatic laparoscopic appendectomy

The subhepatic position of an appendix may lead to difficulty in diagnosis of appendicitis, its surgical management as well as bizarre complications. A 'lost' appendicular faecolith is not an uncommon complication due to spillage during the removal of the appendix or due to perforation. Here we report a case of such a faecolith migrating into the liver parenchyma following intraoperative hepatic injury, and producing a liver abscess. The calcified lesion seen in the liver corresponded to a free-lying faecolith on a preoperative computed tomography scan. Liver abscess was presumed to arise from implantation of this foreign object into the liver parenchyma. Pigtail drainage of abscess was performed with good result.

Pyogenic liver abscess

Pyogenic liver abscess has a variable clinical presentation. Its management requires input from several disciplines and is often coordinated by a gastroenterologist. This review examines demographics, clinical presentation, aetiology, diagnosis and prognosis; a suggested management approach, including antibiotic selection, radiological intervention and indications for surgery, is offered from a physician's perspective.

Prognostic indications of the failure to treat amoebic liver abscesses

OBJECTIVES

To identify the variables that predict the failure to treat amoebic liver abscesses.

METHODS

We prospectively carried out a case-control study on a cohort of patients who had been diagnosed with amoebic liver abscesses using clinical, ultrasonic, and serologic methods. Patients with pyogenic abscesses, negative ELISA tests for amoebiasis, immunosuppression status, or previous abdominal surgery were excluded. All patients received metronidazole, and those who demonstrated 4 days of unfavorable clinical responses received percutaneous or surgical draining of the abscess. Demographic, laboratory, and ultrasonographic characteristics were assessed as prognostic indications of failure.

RESULTS

Of 40 patients with amoebic liver abscess, 24 (mean age: 36·7±11·2 years) responded to medical treatment and 16 (41·8±11·6 years) required drainage, including 14 patients who underwent percutaneous drainage and two patients who required surgery. The albumin level, abscess volume, abscess diameter, and alkaline phosphatase level were all statistically significant (P<0·05) on the bivariate analysis. The highest (>99%) sensitivity and negative predictive value were observed for an abscess volume >500 ml and diameter >10 cm, while the best specificity and positive predictive value were achieved with the combination of low serum albumin level, high alkaline phosphatase level, and large abscess volume or diameter.

CONCLUSIONS

The prognostic indications of the failure to treat amoebic liver abscesses include low albumin, high alkaline phosphatase, and large abscess volume or diameter. The combination of these variables is a useful and easy tool for determining appropriate therapy.

Liver abscesses after peritoneal venous shunt

A 70-year-old man was referred to our hospital for high-grade fever with chills. He has visited our hospital for alcoholic liver cirrhosis and diabetes mellitus for over 20 years. Nine months earlier, he had received a peritoneal venous shunt (Denver shunt®) because of refractory ascites. Laboratory examinations revealed elevated C-reactive protein and liver dysfunction. Ultrasonography and abdominal enhanced computed tomography showed multiple small abscesses in the right lobe of the liver. Blood culture test did not detect the pathogenic bacteria of liver abscesses. The patient was treated with antibiotics for more than 2 months and cured from the infection, but 3 months later, he developed high-grade fever again. He had a recurrence of multiple small liver abscesses involving both lobes of the liver. He was treated with antibiotics, and the abscesses disappeared within a month. After the antibiotic treatment, he had selective intestinal decontamination with kanamycin. He has had no recurrence of liver abscess for over a year. To our knowledge, this is the first report of liver abscess in a cirrhotic patient with Denver shunt. Clinicians should bear liver abscess in mind when treating patients with high-grade fever and liver dysfunction following Denver shunt implantation.

[A case of liver abscess caused by Fusobacterium nucleatum in a patient with recurrent periodontal diseases]

Fusobacteria are anaerobic gram-negative, non-spore forming bacilli found in normal flora of the oral cavity, urogenital tract, and gastrointestinal tract. Fusobacterium nucleatum has been seldom reported as a cause of liver abscess, particularly in immunocompetent hosts. A 55-year-old man with frequent periodontal disease visited our hospital with intermittent fever and headache for 2 months. Abdominal CT scan revealed an 8.2 × 6 cm mass in the right hepatic lobe with central low density. Abscess culture revealed F. nucleatum as the causative organism. Percutaneous abscess drainage and intravenous administration of antibiotics for 4 weeks improved symptoms and decreased the abscess size. We report a rare case of liver abscess due to F. nucleatum in an immunocompetent man with periodontal disease.

Clostridium perfringens liver abscess after pancreatic resection

BACKGROUND

Liver abscess is a rare complication after pancreatectomy. Clostridium perfingens is a rare cause of intrahepatic infections.

CASE REPORT

A 65-year-old woman with pancreatic cancer underwent explorative laparotomy, during which encasement of the hepatic artery by the tumor was found. Neoadjuvant radiochemotherapy with capecitabine was started, which caused tumor regression, and duodenopancreatectomy was performed. The portal vein was occluded and infiltrated by cancer and therefore was resected and not reconstructed. After a slow recovery, the patient developed hemorrhage at the gastrojejunal anastomosis, which was controlled by fibrin injection. Within a few days, she presented with signs of sepsis, and blood cultures yielded Clostridium perfringens, Streptococcus oralis, Staphylococcus aureus, and Candida albicans. The source of the sepsis proved to be a 9-cm liver abscess, which was drained; cultures grew C. perfringens, Hafnia alvei, and Enterobacter cloacae. Despite antibiotic treatment, the patient died from sepsis and multiorgan failure 27 days after pancreatic surgery.

CONCLUSION

Such rare infections can follow pancreatic resection with neoadjuvant radiochemotherapy. Clostridium perfringens-associated liver abscess maintains a high mortality rate.

[Analysis of factors associated to failure of medical treatment of amoebic liver abscess]

INTRODUCTION

To identify the laboratory and ultrasound factors that could predict the response to medical treatment of amoebic liver abscess.

MATERIAL AND METHOD

Retrospective study of patients diagnosis with amoebic liver abscess in Hospital Central in San Luis Potosí, Mexico. We included patients greater than 15 years of both sexes. We excluded those with probable pyogenic abscess, immunosupression, history of abdominal or biliary surgery, abdominal neoplasm abdominal or sepsis. We identified patients with good response to medical treatment and patients who needed the abscess drained. We studied the ultrasound findings, plasma levels of albumin, alkaline phosphatase and bilirubin.

RESULTS

We analysed 45 patients, 31 had a good response (controls) and 14 needed drainage (cases). The medians of the variables with statistical significance in bivariate analysis were: albumin 2.65 g/dl and 1.7 g/dl (p < 0.001); alkaline phosphatase 133 U and 259 U (p = 0.02) and diameter of absences 5.9 cm and 9.95 cm (p < 0.001), controls and cases respectively. By logistic regression the diameter of the abscess showed a determination coefficient of 0.447 (p < 0.05) and OR = 14.85 (95% CI, 2.11-104.9) for drain if it was > or = 8 cm.

CONCLUSIONS

A diameter bigger than 8 cm in hepatic amoebic abscess is associated with failure of medical treatment. Low albumin could be related to malnutrition and increased alkaline phosphatase with extrinsic compression of extrahepatic conducts due to big abscesses.

Simple Liver Cyst as a Focus of Salmonella paratyphi Abscess: A Case Report

Salmonellosis, endemic in various part of the world, is considered a differential diagnosis in a tropical traveller. Although it usually presents as gastroenteritis, its various clinical syndromes may vary from mild gastroenteritis to severe septicaemia including abscess formation, the later two being the most common cause of morbidity and mortality. Here we present a patient who returned to the UK after an overseas trip and was diagnosed with a pyogenic liver abscess with Salmonella paratyphi at a site of a pre-existing simple liver cyst.

Mitogen-activated protein kinase (MAPK) signalling pathways in HepG2 cells infected with a virulent strain of Klebsiella pneumoniae

Klebsiella pneumoniae (KP), an enterobacterium, usually causes urinary tract infection or pneumonia; however, it has caused severe liver abscess in diabetic patients in recent years. How this emerging virulent KP strain causes liver abscess is not known. This study investigates signalling pathways in HepG2 cells infected by virulent KP. Cells were infected with bacteria for various durations and harvested to screen for signalling molecules by Western blotting. Our results showed that phosphorylated mitogen-activated protein kinase (MAPK) kinase (MEK) 1/2, p44/p42 MAPK and p90 ribosomal S6 kinase (p90RSK) were observed and this pathway was inhibited by MEK1/2 inhibitors U0126 and PD98059. Phosphorylation of MEK3/6, p38 kinase and ATF-2 was also observed and this pathway was inhibited by p38 kinase inhibitors SB203850 and SB202190. Toll-like receptor (TLR) 2 and 4 expressions were increased and maximized 2-4 h post infection. The JNK pathway, Elk, MAPKAPK-2 and HSP27 were not activated. These results suggest that KP infections induce signal transduction through TLR2 and TLR4 and activate two downstream MAP kinase pathways, MEK1/2-p44/p42 MAPK-p90RSK and MEK3/6-p38 kinase-ATF-2, but not the JNK pathway in HepG2 cells. The infected HepG2 eventually showed apoptosis and died.

Polycystic liver and kidney diseases

There have been remarkable advances in research on polycystic liver and kidney diseases recently, covering cloning of new genes, refining disease classifications, and advances in understanding more about the molecular pathology of these diseases. Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary disease affecting kidneys. It affects 1/400 to 1/1000 live births and accounts for 5% of the end stage renal disease in the United States and Europe, and is caused by gene defects in the PKD1 or PKD2 genes. Compared to ADPKD, polycystic liver disease (PCLD) is a milder disease and does not lower life expectancy. Both diseases are usually adult-onset diseases. Defects in genes, which code the hepatocystin and SEC63 proteins, have just recently been found to cause PCLD. It now seems that ADPKD is caused by malfunction of the primary cilia, a cell organ sensing fluid movement, and that PCLD is a sequel from defects in protein processing. Autosomal recessive polycystic kidney disease (ARPKD) belongs to a group of congenital hepatorenal fibrocystic syndromes. All ARPKD patients have a gene defect in a gene called PKHD1, the protein product of which localizes to primary cilia. We summarize the present clinical and molecular knowledge of these diseases in this review.