Liver abscesses in children: a single center experience in the developed world

Pyogenic liver abscess in pediatric populations in beijing (2008-2023)

BACKGROUND

Data on pyogenic liver abscess (PLA) of children in China have been limited. We aimed to summarize the clinical feather, microbiological characteristics, management, and outcome of PLA in children.

METHOD

We retrospectively reviewed PLA cases from January 2008 to June 2023 at Beijing Children's Hospital. Clinical characteristics, pathogens and management were analyzed.

RESULTS

We diagnosed 57 PLA patients in our center. The median onset age was 4.5 years and the male-to-female ratio was 1.6:1. The median diagnostic time was nine days and the median length of stay was 22 days. Twenty-eight patients (49.1%) had predisposing factors, around 71.4% of the patients had malignant hematology and primary immunodeficiency disease. Patients with underlying factors were more likely to have extrahepatic organ involvement (p = 0.024), anemia (p < 0.001), single abscess (p = 0.042), unilateral involvement (p = 0.039), and small size of the abscess (p = 0.008). Twenty-four patients (42.1%) had extrahepatic organ involvement. Pathogens were identified in 17 patients (29.8%), the most common pathogens were Klebsiella pneumoniae and Staphylococcus aureus. The positive rate of metagenomic next-generation sequencing (mNGS) was 87.5% (7/8). On multivariable analysis, the extrahepatic organ involved (p = 0.029) and hepatomegaly (p = 0.025) were two independent factors associated with poor outcomes.

CONCLUSIONS

PLA is usually seen in children with predisposing factors. Malignant hematology and primary immunodeficiency disease were the most common underlying diseases. Extrahepatic organ involvement and hepatomegaly are associated with poor prognosis. Increased use of mNGS could be beneficial for identifying pathogens.

Fever of Unknown Origin: A Case Report of Hepatic Phlegmon in an Immunocompetent Patient

Methicillin-resistant Staphylococcus aureus (MRSA) hepatic phlegmon is a rare cause of fever of unknown origin (FUO) in an immunocompetent patient from a high-income country (HIC). MRSA hepatic phlegmon is typically linked to protein malnutrition and chronic gastrointestinal infections in low- to middle-income countries while immunodeficiencies such as chronic granulomatous disease (CGD) are a more common cause in a HIC. Clinical manifestations of hepatic phlegmon can be vague and nonspecific making a complete FUO workup critical during evaluation. We report a case of MRSA hepatic phlegmon in an immunocompetent patient with a nonspecific history and physical exam findings. A 14-year-old male presented with an 11-day history of fever with mild bilateral upper quadrant abdominal pain. The patient also has mild upper quadrant pain with palpation. The patient was diagnosed with a hepatic phlegmon on abdominal ultrasound and computed tomography (CT) of the abdomen. He was started on antibiotics and Interventional Radiology placed drains into the phlegmon and performed vancomycin drain washes. Inflammatory markers were initially elevated and trended down with interventions. The patient did well with treatment and was back to baseline during outpatient follow-up with the Infectious Disease team. This case illustrates the importance of a complete workup in patients with FUO.

Assessment of risk factors in pyogenic liver abscesses in children

Background

Pyogenic liver abscess (LA) is a significant contributor to morbidity and mortality in developing countries like India. The risk factors predisposing to the LA specifically in children are not known. Studies done in the past largely remain inconclusive and have identified only probable causes. The cause of LA in children with no coexisting illness remains unknown.

Methodology

This prospective observational study was conducted at a tertiary teaching hospital located in New Delhi, India. All children between 2 months and 12 years of age with sonographically confirmed LA presenting to the hospital were included and managed with appropriate intravenous antibiotics and relevant investigations.

Results

A total of 52 children were included. The mean age was 6 years and 4 months, and the male: female ratio was 1.4:1. Around 50% of the patients were malnourished. Fever, abdominal pain and loss of appetite were the most common symptoms. Nine patients (17%) were managed conservatively, 13 (25%) needed percutaneous needle aspiration and 30 (57.69%) required drainage using a pigtail catheter. Poor socioeconomic status and anaemia were found to be the most commonly associated risk factors. Selective immunoglobulin A (IgA) deficiency was the most common primary immunodeficiency disorder followed by T-cell defect. On multivariate analysis, it was seen that in those with clinical icterus, gamma-glutamyl transferases >350 IU/m, and those with impending rupture, the time to defervescence was significantly different (P = 0.05).

Conclusion

Poor socioeconomic status causing malnutrition emerged as a significant risk factor for LA in children. Selective IgA deficiency was the most common immunodeficiency seen in a few children. Adopting a conservative approach like aspiration and percutaneous drainage led to lower mortality and good recovery rates.

Pylephlebitis: A Systematic Review on Etiology, Diagnosis, and Treatment of Infective Portal Vein Thrombosis

Pylephlebitis, defined as infective thrombophlebitis of the portal vein, is a rare condition with an incidence of 0.37-2.7 cases per 100,000 person-years, which can virtually complicate any intra-abdominal or pelvic infections that develop within areas drained by the portal venous circulation. The current systematic review aimed to investigate the etiology behind pylephlebitis in terms of pathogens involved and causative infective processes, and to report the most common symptoms at clinical presentation. We included 220 individuals derived from published cases between 1971 and 2022. Of these, 155 (70.5%) were male with a median age of 50 years. There were 27 (12.3%) patients under 18 years of age, 6 (2.7%) individuals younger than one year, and the youngest reported case was only 20 days old. The most frequently reported symptoms on admission were fever (75.5%) and abdominal pain (66.4%), with diverticulitis (26.5%) and acute appendicitis (22%) being the two most common causes. Pylephlebitis was caused by a single pathogen in 94 (42.8%) cases and polymicrobial in 60 (27.2%) cases. However, the responsible pathogen was not identified or not reported in 30% of the included patients. The most frequently isolated bacteria were Escherichia coli (25%), Bacteroides spp. (17%), and Streptococcus spp. (15%). The treatment of pylephlebitis consists initially of broad-spectrum antibiotics that should be tailored upon bacterial identification and continued for at least four to six weeks after symptom presentation. There is no recommendation for prescribing anticoagulants to all patients with pylephlebitis. However, they should be administered in patients with thrombosis progression on repeat imaging or persistent fever despite proper antibiotic therapy to increase the rates of thrombus resolution or decrease the overall mortality, which is approximately 14%.

Liver abscesses in the Western pediatric population

Background and study aims: Liver abscesses are rare in the Western pediatric population and data on predisposing factors and etiology are scarce. We aimed to describe predisposing factors, microbiological characteristics, and treatment. Patients and methods: Retrospective analysis of children admitted to two tertiary care hospitals in Belgium from 1 January 1996 to 31 December 2019. We analyzed clinical features, predisposing factors, imaging characteristics, microbiological data, treatment, and outcome in children with a liver abscess and compared these data with the literature. Results: We collected 24 cases with a male to female ratio of 1.4 and a median age of 3.2 years at time of diagnosis. Survival was 95.8%. Invasive culture specimens were obtained in 83.3% and showed growth of bacteria in 55%. Parenteral antibiotics were administered before invasive culture sampling in 80%. Liver abscesses were cryptogenic in four (16.7%) patients. Hepatobiliary disease was the most prevalent predisposing factor (n = 6; 25%), followed by recent antineoplastic therapy for malignancies (n = 5; 20.8%), intra-abdominal surgical pathology (n = 4; 16.7%) and umbilical venous catheters (n = 2; 8.3%). In two patients there was a parasitic origin (n = 2; 8.3%) and in one it was caused by Bartonellosis. There was no diagnosis of chronic granulomatous disease (CGD) in our cohort. Conclusions: Pediatric liver abscesses have a favorable outcome in the developed world. Whenever feasible, invasive abscess culture specimens should be obtained. In patients presenting with a cryptogenic liver abscess or atypical disease course, immunological workup should be ensured.

Point-of-Care Ultrasound Identification of Portal Vein Thrombosis in a Pediatric Patient

ABSTRACT

Abdominal pain is one of the most common presenting complaints encountered in the pediatric emergency department. The use of point-of-care ultrasonography by emergency physicians has been shown to expedite the diagnosis of a large variety of conditions and can be used to accurately identify intra-abdominal pathology in children. We describe the case of a pediatric patient who presented to the pediatric emergency department with acute abdominal pain, in whom point-of-care ultrasonography helped expedite the diagnosis of acute portal vein thrombosis and liver abscess.

Liver Abscess in Children-experience From a Single Tertiary Care Center of North India: Etiology, Clinical Profile and Predictors of Complications

BACKGROUND

Liver abscess (LA), a common problem in children in the tropics, is believed to be mostly pyogenic (PLA), sometimes amebic (ALA). We aimed to analyze the clinical profile, etiology, risk factors for complications, management and outcomes of LA in children.

METHODS

The details of 81 children with LA managed in a tertiary set up over a period of 3 years were analyzed. A comparison of different parameters was performed with respect to etiology and complications.

RESULTS

ALA, PLA and mixed infection LA were diagnosed in 40 (49.4%), 32 (39.5%) and 9 (11.1%) children. The triad of fever, hepatomegaly and right upper quadrant tenderness was seen in 65 (80.2%). Coagulopathy was observed in 60 (77%) and jaundice in 12 (14.8%). Majority (71.6%) had a single LA in the right lobe (69%). Conservative, percutaneous needle aspiration, percutaneous catheter drainage and surgical drainage were done in 11.1%, 3.7%, 82.7% and 2.5%, respectively. Forty-three (53.1%) had complicated LA with rupture in 55.8% and vascular thrombosis in 16.2%. Children with complicated LA had higher alanine transaminase, prolonged prothrombin time/international normalized ratio, low serum protein and albumin levels (P < 0.05). Median duration of follow-up was 2 months and mean time to resolution of LA was 48.5 ± 18 days.

CONCLUSIONS

ALA is the commonest cause of pediatric LA in endemic regions and is difficult to differentiate from PLA clinically. Percutaneous catheter drainage is safe and effective modality for the management of LA in children. A higher alanine transaminase, prolonged prothrombin time/international normalized ratio and low serum albumin levels (<3 g/dL) at presentation identify complicated LA.

Infant Pyogenic Liver Abscess Complicated With Autoimmune Neutropenia: Two Cases

Approximately 90% of patients with autoimmune neutropenia (AIN) suffer from mild infections although neutrophil count often decreases to <500/μL. Here, we report 2 cases of infant pyogenic liver abscess complicated with AIN. We should consider the possibility of AIN as an underlying disease when diagnosing pyogenic liver abscess during childhood.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Pediatric Liver Abscess: Trends in the Incidence, Etiology, and Outcomes Based on 20-Years of Experience at a Tertiary Center

Background: Liver abscess is an important but relatively rare disease in children. This study investigated the clinical characteristics of eligible patients at a referral tertiary center over the past two decades. Method: A 20-year retrospective study (January 2000-December 2019) enrolled 38 children diagnosed with liver abscess. Demographic data; clinical features; laboratory, imaging, and microbiological findings; management strategy; and outcomes were reviewed from the patients' medical records. Results: Thirty-eight cases of pyogenic liver abscess were identified without a culture-proven amebic or fungal abscess. The mean age of diagnosis was 9.6 ± 6.2 years, and the male-to-female ratio was 1.92: 1. Hemato-oncological (28.9%) and predisposing hepatobiliary diseases (23.7%) were the two most common predisposing factors. Fever (94.7%) was the most common presentation followed by right upper quadrant abdominal pain (42.1%) and pleural effusion (34.2%). Among the laboratory parameters, leukocytosis was common (70.3%), and all patients had elevated serum C-reactive protein levels. Increased serum levels of alanine aminotransferase, aspartate aminotransferase, direct bilirubin, and total bilirubin were found in 40.5, 48.6, 23.1, and 42.9% of the cases, respectively. The most common pathogen in blood and pus cultures was Klebsiella pneumoniae. The mean durations of intravenous antibiotic and total antibiotic use were 29.0 ± 15.7 and 45.1 ± 22.1 days, respectively. Twelve patients (31.6%) were treated with antibiotics alone, while percutaneous needle aspiration, percutaneous pigtail drainage, and surgical intervention were performed in 12 (31.6%), 10 (26.3%), and 5 (13.2%) patients, respectively. No mortality was documented in this series. Conclusion: The present study reflects a relatively declining incidence of liver abscess compared with prior studies in Taiwan. K. pneumoniae remains the most prevalent pathogen in both blood and abscess cultures in Taiwan. Proper antimicrobial therapy with timely drainage generally yielded an adequate treatment response without any mortality.

Host-derived fatty acids activate type VII secretion in Staphylococcus aureus

The type VII secretion system (T7SS) of Staphylococcus aureus is a multiprotein complex dedicated to the export of several virulence factors during host infection. This virulence pathway plays a key role in promoting bacterial survival and the long-term persistence of staphylococcal abscess communities. The expression of the T7SS is activated by bacterial interaction with host tissues including blood serum, nasal secretions, and pulmonary surfactant. In this work we identify the major stimulatory factors as host-specific cis-unsaturated fatty acids. Increased T7SS expression requires host fatty acid incorporation into bacterial biosynthetic pathways by the Saureus fatty acid kinase (FAK) complex, and FakA is required for virulence. The incorporated cis-unsaturated fatty acids decrease Saureus membrane fluidity, and these altered membrane dynamics are partially responsible for T7SS activation. These data define a molecular mechanism by which Saureus cells sense the host environment and implement appropriate virulence pathways.

Protocol-based management of 154 cases of pediatric liver abscess

AIM

Although liver abscess (LA) is prevalent worldwide, especially in developing countries, there is a paucity of data regarding the protocol for management of LA in children. The aim of this study was to analyze the outcome of a protocol-based management of pediatric LA from a single institution.

MATERIALS AND METHODS

This prospective observational study was conducted in a tertiary-care children's hospital and included all patients with LA managed over a 5-year period. Detailed clinical, laboratory, microbiological and imaging parameters were recorded, and the patients were treated according to a standardized management protocol. Small abscesses (<5 cm) and those with solid appearance on initial ultra-sonogram (US) were managed with antimicrobial therapy alone. Liquefied abscesses on imaging were additionally subjected to US guided percutaneous needle aspirations (PNA). Large abscesses pointing to the surface were treated by percutaneous drainage (PCD). Ruptured LA, abscess inaccessible to image-guided drainage and those not responding to other modes of treatment were subjected to open surgical drainage (OSD). Pleural collections were treated by aspirations or intercostal tube drainage. Outcome was analyzed in terms of duration of recovery and complications including mortality.

RESULTS

Over the 5-year period, 154 pediatric LA patients underwent protocol-based management. The mean age of the patients was 6.76 years with the male:female being 1.26:1. Medical management alone, PNA, PCD and OSD were successful in 38 (24.6%), 76 (49.3%), 11 (7.14%) and 29 (18.8%) cases, respectively. Pleural collections developed in 43 (27.9%) patients out of which aspiration/drainage was needed in 24 (55.81%) cases. The mean duration of hospital stay was 20.67 ± 9.52 days. Ongoing sepsis and multi-organ failure lead to mortality in 6 (3.8%) cases; rest of the patients were doing well on follow-up.

CONCLUSION

Ultra-sonography was useful for the initial diagnosis, monitoring the progress and management of LA in children. The outcome of a protocol-based management of LA in children was favorable.

A conceptual and practical approach to haemostasis in paediatric liver disease

Children with liver disease can develop severe bleeding episodes and thrombosis. Liver failure usually results in decreased levels of procoagulant and anticoagulant factors. Additional risk factors, including changes in vascular flow and endothelial function, are of importance for the development of bleeding or thrombosis in individual vascular beds. Detailed studies of haemostatic disturbances in the setting of paediatric liver disease are sparse and extrapolation from adult studies is common. The spectrum of liver diseases and the haemostatic system differs between children and adults. Specific paediatric liver diseases are reported to have more distinctive effects on haemostasis and the risk of bleeding and/or thrombosis.

CONCLUSION

we propose a model regarding haemostasis in paediatric liver disease, taking into account a number of specific variables and mechanisms, as well as the type of liver disease, which will provide a framework for clinical decision-making in these complex patients.

Pyogenic Liver Abscess with Delayed Presentation After Appendectomy

Liver abscess is a serious condition that is uncommon in otherwise normal children. Predisposing factors include immunosuppression, surgery and travel to certain areas. We present a patient with liver abscess 4 months after appendectomy. In addition, we reviewed 7 cases of liver abscess that occurred in a 22-year period.

[Particularities of liver abscesses in children in Senegal: Description of a series of 26 cases]

Liver abscess is a serious infection that can cause life-threatening complications.

OBJECTIVE

To describe the epidemiology, diagnosis, and progression of liver abscess at the Dakar National Albert-Royer Children's Hospital.

METHOD

A retrospective study was conducted from over a period of 5 years (1st January 2010 to 31st December 2014). All children aged 0-15 years hospitalized for liver abscess with ultrasound confirmation were included. We collected demographic data (age, gender, socioeconomic status, origin), clinical data (general and hepatic symptoms), diagnostic data (ultrasound, bacteriology) and progression (death, complications, sequelae). The data were analyzed with Epi-info (P<0.05 was considered significant).

RESULTS

We collected 26 cases of liver abscesses, representing a hospital prevalence of 100 cases per 100,000 admissions. Males predominated (sex ratio: 1.36). The children's average age was 7.2 years. Most of the children came from urban areas of Dakar. Low socioeconomic status and precarious lifestyle were the contributing factors. Anemia (69.2%), malnutrition (42.3%), and abdominal trauma (15.3%) were the main causes found. The Fontan triad characteristic of the liver abscess was found in 57.7% of cases. At ultrasound, a single abscess was found in 21 cases. The abscess was located in the right lobe in 18 cases, the left lobe in three cases, and in both lobes in three cases. Segment VI (four cases) was the most frequently involved. Bacteriologically, the abscess was pyogenic in 17 cases and an amoebic abscess in nine cases. The main pyogenic sources found were Klebsiella pneumoniae in two cases, Pseudomonas aeruginosa in one case, Streptococcus pneumoniae in one case, and Staphylococcus aureus in one case. The average duration of antibiotic treatment was 14.5 days. Liver drainage was carried out in 24 cases. The outcome was favorable in all children.

CONCLUSION

The prevalence of liver abscesses at the Albert-Royer Children's Hospital is relatively high, compared to the literature data. Percutaneous drainage combined with antibiotics remains the treatment of choice. The prognosis is favorable.

Percutaneous drainage of abdominal and pelvic abscesses in children

It has only been in the last several decades that abscesses within deep compartments, particularly within the abdomen and pelvis, have become safely accessible with imaging guidance. Since that time, percutaneous abscess drainage has become the standard of care in children. We review the clinical features, diagnosis, and image-guided management of abdominal and pelvic abscesses in children.

Klebsiella pneumoniae liver abscess in an immunocompetent child

Klebsiella pneumoniae has emerged as a leading pathogen that causes pyogenic liver abscesses (PLAs) in Korea. K. pneumoniae liver abscess (KLA) is potentially life threatening, and the diagnosis is difficult. In developed countries, PLA is rarely observed in children and is frequently associated with disorders of granulocyte function and previous abdominal infection. We observed a case of KLA in a healthy 12-year-old boy. To our knowledge, this is the first reported case of KLA in an immunocompetent child without an underlying disease in Korea. The patient was treated with percutaneous catheter drainage and antibiotics. The catheter was placed in the intrahepatic abscess for 3 weeks and parenteral antibiotics (ceftriaxone and amikacin) were administered for 4 weeks, followed by oral antibiotics (cefixime) for 2 weeks. We reported this case to raise awareness of KLA in immunocompetent children among physicians, and to review the diagnosis, risk factors, potential complications, and appropriate treatment of KLA.

Imaging of multifocal liver lesions in children and adolescents

Multifocal liver lesions are encountered regularly in children and adolescents. By knowing the specific ultrasonographic, computed tomographic, and magnetic resonance imaging (MRI) features of benign and malignant pediatric liver lesions as well as the particular clinical setting, radiologists can frequently narrow the differential diagnosis and sometimes offer a definitive diagnosis. The purpose of this review article is to illustrate the imaging findings of numerous benign and malignant causes of multifocal liver lesions in the pediatric population.

Microbiology and Management of Pediatric Liver Abscesses: Two Cases Caused by Streptococcus anginosus Group

Pyogenic liver abscesses in the pediatric population are rare occurrences in the developed world. We present two cases of previously healthy males presenting with fever and abdominal pain found to have liver abscesses due to organisms in the Streptococcus anginosus group. The microbiology of S. anginosus along with the management and recommended treatment in children with liver abscesses is discussed.

Abscesso hepático de origem hematogênica em paciente com febre de origem indeterminada

OBJETIVO: Descrever uma apresentação atípica de abscesso hepático em paciente pediátrico e realizar uma revisão da literatura no que diz respeito às diferenças observadas na etiopatogenia do quadro, quando considerados os países desenvolvidos e aqueles em desenvolvimento. DESCRIÇÃO DO CASO: Paciente de 13 anos, do sexo masculino, foi trazido ao pronto-socorro pediátrico devido à febre diária e à perda de peso, sem alterações ao exame físico. Na investigação realizada, o ultrassom abdominal evidenciou área heterogênea nodulariforme relativamente definida, compatível com abscesso hepático. Foi realizada drenagem cirúrgica e antibioticoterapia. No material da drenagem houve crescimento de Staphylococcus aureus sensível à oxacilina. COMENTÁRIOS: O caso demonstra a importância de o pediatra conhecer as principais causas da febre de origem indeterminada, saber desenvolver a abordagem investigativa e, frente ao diagnóstico de abscesso hepático, aferir a possibilidade de o agente etiológico ser o Staphylococcus aureus, principalmente quando houver relato de rotura da pele.

[Management of pediatric liver abscess]

Liver abscess in the pediatric population remains uncommon in developed countries, except in cases of septicemia or in children with major debilitating diseases, granulocyte dysfunction, or immunosuppression. Although much is known about the etiopathogenesis of liver abscess, the gold standard of investigations and treatment is still debatable in developing countries. We report the case of a 6-year-old child living in Reunion Island, with no medical history, presenting with right and pyretic abdominal pain in the right upper quadrant. Ultrasound and CT scan showed a large hypodense nonenhanced area in segment IV. Final diagnosis was, by exclusion, pyogenic liver abscess based on negative serology, recent liver lesion, and normal tumor test results, even if blood culture remained negative. No percutaneous puncture was done because of positive outcome after 4 days of antibiotics. Treatment consisted in three intravenous antibiotics (ceftriaxone, aminoxide, and metronidazole) until complete biological normalization. Ultrasound remained normal 3 months later. Even if liver abscess is uncommon in developing countries, the diagnosis must be raised in cases of isolated liver tumor with fever. Management in the nonimmunosuppressed child must be discussed associating parenteral antibiotic therapy, percutaneous drainage, or surgery in very uncommon cases, according to the liver location and first day's progression. Etiological investigation such as colonoscopy in adults must be adapted to pediatric data.

Identification of high-risk group and therapeutic options in children with liver abscess

The outcome of children with liver abscess (LA) depends upon prompt diagnosis and intervention. We evaluated the etiology, clinical profile, various interventional modalities of management and outcome of children with LA. A total of 39 hospitalized children (mean age 7.2 ± 3.9 years) with radiologically proven LA were analyzed. Parenteral antibiotics, percutaneous drainage (PD) or open surgical drainage (OSD) was done as required. Cases with ruptured or impending rupture of LA, upper gastrointestinal bleed, jaundice, pleural effusion or consolidation were labeled as "high risk" cases. Triad of fever, pain and hepatomegaly was the most common presentation. Single abscess was present in 66.7% and right lobe was involved in 69.2% of cases. Majority of LA were pyogenic (PLA, 25/39). Amebic liver abscess (ALA) and PLA had similar clinical and laboratory profile except that multiloculated abscess on ultrasonography was a feature of PLA (12/25 vs. 0/11; p = 0.006). Cases with ALA settled significantly more often with antibiotics alone (5/11 vs. 3/25; p = 0.04) than PLA and none required surgery (0/11 vs. 7/25; p = 0.03). Subjects with "high-risk" LA (n - 26) had significantly larger abscesses, more polymorphonuclear leucocytosis (74 ± 15% vs. 61 ± 13%; p = 0.01) in peripheral blood and need of drainage (24/26 vs. 7/13; p = 0.03) than patients with average-risk LA. Based on the results, 38/39 children recovered, with complete abscess resolution in 28, over 48 ± 63.8 days. In conclusion, ALA, although similar in presentation, are uniloculated, and patients with ALA recover more often without drainage than patients with PLA. Patients with "high risk" LA are more common and have a good outcome with drainage. PD, being safe, efficacious and less invasive than OSD, should be the preferred drainage procedure.

Liver abscess in children: a 10-year single centre experience

BACKGROUND/AIM

Although liver abscess is more prevalent in developing countries than in developed countries, there is scant data about the characteristics of pediatric liver abscess in our region. We aimed to analyze the characteristics of pediatric liver abscess in our region and compare these with those of developed countries.

MATERIALS AND METHODS

The clinical features, laboratory, imaging, microbiologic findings, management strategy, and final outcome were extracted from the patients' records retrospectively.

RESULTS

There were 18 cases of liver abscess including 16 pyogenic liver abscess, one amebic liver abscess and one candida liver abscess. Fever and abdominal pain were the most common clinical findings and leukocytosis was the most common laboratory finding. The most predisposing factors of liver abscess were immune deficiency, minor thalassemia. Origin of liver abscess was appendicitis in two patients, the rest were considered as cryptogenic. While one patient was treated with antibiotics alone, five cases were taken for open drainage, and 12 cases were treated with percutaneous aspiration. Percutaneous aspiration failed in two patients who were later taken for open drainage, with an overall mortality rate of 5.5%.

CONCLUSION

The overall characteristics of liver abscess in children in our society are not so different from developed countries. However, in contradiction to cases reported in developed countries, most cases of liver abscess were seen in healthy patients in our centre. Moreover, liver abscess was reported in our patients at a younger age and was more commonly seen in male children. Mortality rate was similar to that of developed countries.

Gastrointestinal intervention in children

Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described.

Granulomatous appendicitis in a 12-year-old boy

Isolated granulomatous inflammation of the appendix is extremely rare, and its etiology is still unknown. We describe a 12-year-old boy with isolated granulomatous appendicitis where the etiology could not be clarified despite infectious criteria such as high fever and gastroenteritis. Children with epithelioid granulomatous appendicitis have a good prognosis following appendectomy.

Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome

Pylephlebitis is a condition with significant morbidity and mortality. We review herein 100 relevant case reports published since 1971. Eighty-one patients were reported with acute pylephlebitis, while the remaining patients had chronic pylephlebitis. The most common predisposing infections leading to pylephlebitis were diverticulitis and appendicitis. Cultures from blood or other tissues were positive in 77%. The infection was polymicrobial in half of the patients and the most common isolates were Bacteroides spp, Escherichia coli and Streptococcus spp. Thrombosis was extended to the superior mesenteric vein (SMV), splenic vein, and intrahepatic branches of the portal vein (PV) in 42%, 12%, and 39%, respectively. Antibiotics were administered in all and anticoagulation in 35 cases. Patients who received anticoagulation had a favourable outcome compared to those who received antibiotics alone (complete recanalization 25.7% vs 14.8% (p > 0.05), no recanalization 5.7% vs 22.2% (p < 0.05), and death 5.7% vs 22.2% (p < 0.01)). Cases with complete recanalization had prompt diagnosis and management and two-thirds were recently published. Nineteen patients died; the majority of these (73.7%) died over the period 1971-1990. In conclusion, pylephlebitis remains an entity with high morbidity and mortality, but modern imaging modalities have facilitated an earlier diagnosis and have improved the prognosis. Anticoagulation has a rather beneficial effect on patients with pylephlebitis.

[Pylephlebitis in the child: a challenging diagnosis]

Pylephlebitis or septic thrombophlebitis of the portomesenteric veins is a complication of intra-abdominal infections. The disease is rare in children and the diagnosis is often delayed. The morbidity of pylephlebitis is relatively low, although there is a risk of residual thrombosis. We report on 2 cases of pylephlebitis in a 12-year-old girl and a 13-year-old boy, following undiagnosed appendicitis. In the 1st case, the young girl had been misdiagnosed with Salmonella infection and was given antibiotics; in the 2nd case, the boy had retrocecal appendicitis that was clinically subacute. An accurate diagnosis was finally made in both cases by CT scan. Both children evolved satisfactorily following appendectomy, long-term antibiotics, and anticoagulation. Clinically, the severe sepsis associated with pylephlebitis is at the forefront. Physical examination is often normal and therefore of little help; the knowledge of a preceding abdominal infection leads to further radiological investigations. Biologically, there are pronounced signs of infection. CT is the preferred exam for diagnosing pylephlebitis, as it can also show the underlying cause of the intra-abdominal sepsis or possible complications. Doppler sonography is recommended more for follow-up of the portal vein thrombosis. Treatment of pylephlebitis associated with appendicitis always includes long-term antibiotics. An appendectomy is always performed either at the time of diagnosis or later. The need for anticoagulation therapy in children is controversial. However, most pediatricians recommend its use, beginning as soon as possible, to be continued until normalization of portal vein flow.

Liver abscess in children: an overview

BACKGROUND

Liver abscess (LA) in the pediatric population has become relatively uncommon in developed countries but it continues to have a high incidence among children in developing countries. This article aims to review the trends in all aspects of LA in children, both temporally and geographically.

DATA SOURCES

The PubMed and Google Scholar database were searched with the keywords "liver abscess", "children", "predisposing causes", "clinical signs and symptoms", "treatment" from 1975 to 2009 and all kinds of retrospective and prospective studies, reviews, case series were included.

RESULTS

Pyogenic LA constitutes the majority of cases, followed by amebic and fungal LA. Staphylococcus aureus is the most common pathogen worldwide. Ultrasonography (US) and computed tomography (CT) are widely used as diagnostic tools. There are varying opinions regarding the treatment of LA in children. The general trend is towards less invasive modalities of treatment like percutaneous drainage along with antimicrobial drug therapy. However, in selected patients, open surgical drainage still plays an important role. The mortality rate for pyogenic LA has shown a decline from about 40% before the 1980s to less than 15% in the recent years. At the same time, the mortality rate of amebic LA cases reported to be around 11%-14% before 1984 has reduced to less than 1% at present.

CONCLUSIONS

Etiological pattern of LA in children has remained the same over the years, and in most regions, it is associated with Staphylococcus aureus and amebic LA is quite uncommon. US or CT scan is the most frequently employed diagnostic modality for LA, and follow-up is usually performed by serial US scans. Antimicrobial therapy along with, if necessary, drainage of the abscess by either percutaneous or open surgical route remains the treatment of choice.

Pyogenic liver abscess secondary to Streptococcus anginosus in an adolescent

Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort.

Chronic granulomatous disease

Chronic granulomatous disease (CGD) is a rare congenital immunodeficiency characterized by recurrent bacterial and fungal infections as well as granuloma formation. The manifestations of this disease can involve single or multiple organ systems. The lungs are the most commonly affected organ; however, lymphatic, hepatic, skeletal, gastrointestinal, genitourinary, head and neck, and central nervous system involvement have also been described. Most patients present with symptoms in their first few years of life. Due to the nonspecific manner in which patients present, the pediatric radiologist may be among the first to recognize the pattern of infection, inflammation, and granuloma formation leading to a diagnosis of CGD. The purpose of this paper is to review the imaging findings of CGD that can manifest throughout the body.

Two-year-old boy with cervical and liver abscesses

Pyogenic liver abscesses are rare in children but relatively common in those with chronic granulomatous disease (CGD). We present a case of a 2 year old boy who initially presented with BCGitis and Staphylococcus aureus cervical adenitis, and then subsequently developed liver abscesses. A diagnosis of X-linked CGD was confirmed. This case demonstrates the typical radiological features of liver abscesses in CGD, its management without surgical intervention, and the increasingly recognised complications of BCG vaccination in CGD.

Immunological mechanisms underlying the genetic predisposition to severe Staphylococcus aureus infection in the mouse model

Host genetic variations play a significant role in conferring predisposition to infection. In this study, we examined the immune mechanisms underlying the host genetic predisposition to severe Staphylococcus aureus infection in different mouse strains. Whereas C57BL/6 mice were the most resistant in terms of control of bacterial growth and survival, A/J, DBA/2, and BALB/c mice were highly susceptible and succumbed to infection shortly after bacterial inoculation. Other strains (C3H/HeN, CBA, and C57BL/10) exhibited intermediate susceptibility levels. Susceptibility of mice to S. aureus was associated with an inability to limit bacterial growth in the kidneys and development of pathology. Resistance to S. aureus in C57BL/6 mice was dependent on innate immune mechanisms because Rag2-IL2Rgamma(-/-) C57BL/6 mice, which are deficient in B, T, and NK cells, were also resistant to infection. Indeed, neutrophil depletion or inhibition of neutrophil recruitment rendered C57BL/6 mice completely susceptible to S. aureus, indicating that neutrophils are essential for the observed resistance. Although neutrophil function is not inhibited in A/J mice, expression of neutrophil chemoattractants KC and MIP-2 peaked earlier in the kidneys of C57BL/6 mice than in A/J mice, indicating that a delay in neutrophil recruitment to the site of infection may underlie the increased susceptibility of A/J mice to S. aureus.