Computed tomographic differences of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-Klebsiella pneumoniae

Endogenous Endophthalmitis From a Klebsiella pneumoniae Liver Abscess: The Incidence, Risk Factors, and Utility of Imaging

PURPOSE

We investigated the rate of ophthalmologic examinations to detect endogenous endophthalmitis in patients with pyogenic liver abscesses (PLAs) and the incidence and risk factors of endophthalmitis from a PLA caused by Klebsiella pneumoniae (PLA-K).

DESIGN

Retrospective case series.

METHODS

A total of 536 patients admitted to a university hospital in Korea to treat PLAs during 2012-2022 were included. The proportion of patients who were referred for ophthalmologic examinations was investigated and the incidence of endophthalmitis in 248 patients with PLA-K was calculated. Univariate and multivariate logistic regression analyses were performed to define risk factors including demographic characteristics, underlying diseases, radiologic findings, and systemic conditions.

RESULTS

A comprehensive ophthalmologic examination was performed in 73.7% of all patients with PLAs, and the incidence of endophthalmitis from a PLA-K was 7.3%. A liver abscess >5 cm increased the incidence of endogenous endophthalmitis 4-fold compared with smaller abscesses (odds ratio [OR] = 4.01 [95% confidence interval {CI}, 1.02-15.78], P = .047) and portal or hepatic vein thrombophlebitis increased the incidence approximately 4-fold (OR = 4.04 [95% CI, 1.10-14.83], P = .036). Acute cholangitis was approximately 8-fold (OR = 8.33 [95% CI, 1.25-55.71], P = .029), and disseminated intravascular coagulation was approximately 6-fold (OR = 5.76 [95% CI, 1.22-27.21], P = .027) more related to prevalence of endophthalmitis. Other extrahepatic infections increased the incidence approximately 43-fold (OR = 43.06 [95% CI, 10.14-182.90], P < .001).

CONCLUSIONS

Clinicians should consider the risk of endogenous endophthalmitis when PLA-K patients have large liver abscesses (>5 cm), acute cholangitis, portal or hepatic vein thrombophlebitis, disseminated intravascular coagulation, or other extrahepatic infections.

Demographics, Radiological Findings, and Clinical Outcomes of Klebsiella pneumonia vs. Non-Klebsiella pneumoniae Pyogenic Liver Abscess: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Pyogenic liver abscess (PLA) is a common cause of hepatobiliary sepsis. Klebsiella pneumoniae (KP) is the most common organism causing PLA. Evidence is scarce on the demographics, radiological findings, and outcomes of KPPLA versus non-KPPLA (N-KPPLA). PubMed, Embase, The Cochrane Library, and Scopus were systematically searched until 14 May 2022 for studies comparing KPPLA and N-KPPLA. Exclusion criteria were single-arm studies. Primary outcomes were mortality (30-day/in-hospital) and metastatic complications. There were 16 studies, including 5127 patients (KPPLA n = 3305, N-KPPLA n = 1822). Patients with KPPLA were younger (mean difference: −2.04 years, p = 0.02). History of hepatobiliary disease (Odds ratio (OR) 0.30, 95% CI: 0.20, 0.46) and malignancy (OR 0.26, 95% CI: 0.16, 0.42) were less common in KPPLA. KPPLA was associated with lower incidence of multiple abscesses (OR 0.52, 95% CI: 0.35, 0.76, p < 0.001) and bilobar abscesses (OR 0.60, 95% CI: 0.49, 0.74, p < 0.001). KPPLA has higher overall metastatic complications (KPPLA 9.7% vs. N-KPPLA 4.8%, OR 3.16, 95% CI: 2.00, 4.99, p < 0.001), but lower mortality (KPPLA 3.9% vs. N-KPPLA 7.6%, OR 0.51, 95% CI: 0.34, 0.78, p < 0.001). Trial sequential analysis showed conclusive evidence that KPPLA has lower mortality than N-KPPLA. In conclusion, KPPLA has lower mortality than N-KPPLA.

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.

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.

Contrast-Enhanced Ultrasound Appearance of Hypervirulent Klebsiella pneumoniae Liver Abscesses

There has been a paradigm shift with Klebsiella pneumoniae (KP) emerging as the most frequently isolated bacterium in pyogenic liver abscesses in immunocompetent patients. Colonization of this hypervirulent KP strain has led to community-acquired liver abscesses. Septic seeding to distant sites of the body has been recognized and is strongly associated with diabetes. Contrast-enhanced computed tomographic features have been described. Grayscale ultrasound (US) features remain inconclusive, with variable US appearances. Here we describe the contrast-enhanced US features of KP liver abscesses, which correlated with previously described computed tomographic findings. The use of contrast-enhanced US eliminates the need for radiation exposure.

Clinical and computed tomography features of extended-spectrum β-lactamase-producing Klebsiella pneumoniae liver abscess

Background

Klebsiella pneumoniae (KP) is the primary pathogen associated with pyogenic liver abscesses (PLAs). Moreover, there has been an increase in the proportion of extended-spectrum beta-lactamase (ESBL)-producing KP. However, the clinical and computed tomography (CT) features of liver abscesses caused by ESBL-producing KP have not been separately described. We aimed to compare the clinical and CT features present in patients with ESBL-producing and non-ESBL-producing KP as well as to determine the risk factors for ESBL-producing KP liver abscesses (KPLAs).

Methods

We performed a retrospective analysis of data obtained from the medical records of patients with a first episode of KPLA admitted to Shengjing Hospital of China Medical University between May 2015 and May 2019. We compared the clinical and CT features between patients with ESBL-producing and non-ESBL-producing KPLA.

Results

We enrolled 100 patients with KPLA (14 and 86 in the ESBL-producing and non-ESBL-producing groups, respectively). There was no significant between-group difference in the proportion of patients with comorbid diabetes (71.43% vs. 66.2%, p = 0.086). The ESBL-producing KPLA group had a greater proportion of patients with a history of biliary disease (78.57% vs. 26.74%, p < 0.001) and gastrointestinal malignancy (50% vs. 6.98%, p < 0.001). Multivariate regression analysis showed that a history of biliary disease was an independent risk factor for ESBL-producing KPLA. Compared with the non-ESBL-producing KPLA group, the ESBL-producing KPLA group had a significantly higher intensive care unit (ICU) admission rate (28.57% vs. 2.33%, p < 0.001). All ESBL-producing KP isolates were susceptible to carbapenems and amikacin. Only the presence of multiloculation on CT was found to be significantly different between the groups (50% vs. 82.56%, p = 0.012).

Conclusions

The presence of biliary disease was an independent risk factor for ESBL-producing KPLA. Patients with ESBL-producing KPLA had a higher ICU admission rate, with only half of patients having evidence of multiloculation on CT.

Hypervirulent Klebsiella pneumoniae

Hypervirulent K. pneumoniae (hvKp) is an evolving pathotype that is more virulent than classical K. pneumoniae (cKp). hvKp usually infects individuals from the community, who are often healthy. Infections are more common in the Asian Pacific Rim but are occurring globally. hvKp infection frequently presents at multiple sites or subsequently metastatically spreads, often requiring source control. hvKp has an increased ability to cause central nervous system infection and endophthalmitis, which require rapid recognition and site-specific treatment. The genetic factors that confer hvKp's hypervirulent phenotype are present on a large virulence plasmid and perhaps integrative conjugal elements. Increased capsule production and aerobactin production are established hvKp-specific virulence factors. Similar to cKp, hvKp strains are becoming increasingly resistant to antimicrobials via acquisition of mobile elements carrying resistance determinants, and new hvKp strains emerge when extensively drug-resistant cKp strains acquire hvKp-specific virulence determinants, resulting in nosocomial infection. Presently, clinical laboratories are unable to differentiate cKp from hvKp, but recently, several biomarkers and quantitative siderophore production have been shown to accurately predict hvKp strains, which could lead to the development of a diagnostic test for use by clinical laboratories for optimal patient care and for use in epidemiologic surveillance and research studies.

Metastatic endophthalmitis and thyroid abscess complicating Klebsiella pneumoniae liver abscess

The thyroid is resistant to infection due to its anatomical and physiological characteristics. We present a rare case of invasive liver abscess with metastatic thyroid abscess and endogenous endophthalmitis in a previously healthy 55-year-old female patient without diabetes or other medical illness. This report raises an important question of the virulence of Klebsiella pneumoniae as an increasingly common causative agent of liver abscess.

Klebsiella pneumonia liver abscess syndrome: Case presentation to a college student health clinic

The authors describe a case of Klebsiella pneumoniae liver abscess (KPLA) in a student presenting to a university student health center. The authors also provide a review of KPLA and invasive Klebsiella pneumoniae liver abscess syndrome (IKPLAS), including epidemiology, common clinical manifestations, standard diagnostic work-up, management options, and potential complications.

Multimodality Imaging of Liver Infections: Differential Diagnosis and Potential Pitfalls

Imaging plays an important role in the diagnosis, characterization, and management of infectious liver disease. In clinical practice, the main contributions of imaging are in detecting early disease, excluding other entities with a similar presentation, establishing a definitive diagnosis when classic findings are present, and guiding appropriate antimicrobial, interventional, or surgical treatment. The most common imaging features of bacterial, viral, parasitic, and fungal hepatic infections are described, and key imaging and clinical manifestations are reviewed that may be useful to narrow the differential diagnosis and avoid pitfalls in image interpretation. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging allow accurate detection of most hepatic infections and, in some circumstances, may provide specific signs to identify the underlying pathogen and exclude other entities with similar imaging features. In bacterial and parasitic infections, specific imaging features may be enough to exclude a neoplasm and, occasionally, to identify the underlying infectious agent. US and CT are important means to guide percutaneous aspiration or drainage when needed. In viral infections, imaging is critical to exclude entities that may manifest with similar clinical and laboratory findings. Disseminated fungal infections require early detection at imaging because they can be fatal if not promptly treated. Familiarity with the epidemiology, pathogenesis, clinical manifestations, imaging features, and treatment of hepatic infections can aid in radiologic diagnosis and guide appropriate patient care. (©)RSNA, 2016.

Impact of Regional Vein Thrombosis in Patients with Klebsiella pneumoniae Liver Abscess

Klebsiella liver abscess (KLA) is an emerging infection in Asia caused by hypermucoviscous strains of Klebsiella pneumoniae. It is associated with thrombophlebitis of portal and hepatic veins. The natural history and role of anticoagulation for this regional thrombophlebitis is unclear. In a retrospective study of 169 subjects with KLA over 7 years, thrombophlebitis was identified in 53/169 (31.4%). Only 1 received therapeutic anticoagulation. Despite this 30/49 (73.2%) of those with follow up scan available showed improvement or recanalization (mean duration between scans 44 days). Abscess resolution was associated with improvement in thrombophlebitis.

Pyogenic Liver Abscess: Does Escherichia Coli Cause more Adverse Outcomes than Klebsiella Pneumoniae?

BACKGROUND

This paper aims to demonstrate if Escherichia coli pyogenic liver abscess (ECPLA) results in adverse outcomes compared to Klebsiella pneumoniae PLA (KPPLA).

METHODS

A retrospective review of all patients admitted at a tertiary hospital in Singapore from 2003 to 2011 was performed. Patients with age <18 years, amoebic liver abscess, infected liver cyst, culture negative abscess or ruptured liver abscess requiring urgent surgical intervention were excluded. Only patients with blood or pus culture confirmation of ECPLA (n = 24) or KPPLA (n = 264) were included. Median length of hospital stay, failure of non-operative therapy and 30-day mortality are the reported outcomes.

RESULTS

ECPLA affects older patients (68 vs. 62 years, p = 0.049). Ischemic heart disease was more common in ECPLA (29 vs. 14 %, p = 0.048) and there was no difference in diabetic state (42 vs. 38 %, p = 0.743). ECPLA is more commonly associated with hyperbilirubinemia (60 vs. 34 µmol/L, p = 0.003), increased gamma-glutamyl transpeptidase (236 vs. 16 IU/L, p = 0.038) and gallstones (58 vs. 30 %, p = 0.004). KPPLA are larger in size (6 vs. 4 cm, p = 0.006) and had percutaneous drainage (PD) more frequently (64 vs. 42 %, p = 0.034). There was no difference in median hospital stay (14 vs. 14 days, p = 0.110) or 30-day mortality (17 vs. 10 %, p = 0.307) between ECPLA and KPPLA. Among patients with ECPLA, antibiotic treatment with PD appeared to have higher mortality compared to antibiotic treatment alone (30 vs. 7 %) but this was not significant (p = 0.272).

CONCLUSION

In the setting of multimodal care, outcomes of ECPLA are comparable to KPPLA.

Contrast-enhanced ultrasound in different stages of pyogenic liver abscess

To enable sonographic classification of different stages of pyogenic liver abscesses, sonographic findings in 86 patients with 113 pyogenic liver abscesses were retrospectively analyzed and compared with established pathomorphologic descriptions of the disease. The typical findings in contrast-enhanced ultrasound were sub-segmental hyperemia (93/113, 82%) and necrosis with a hyperemic margin (109/113, 96%) in the arterial phase and a washout of liver tissue surrounding necrosis in the late phase (101/113, 89%). Four different sonomorphologic stages of pyogenic liver abscess were identified. Stage I was defined by focal inflammation without necrosis (n = 2); stage II by focal clusters of micro-abscesses appearing to coalesce (n = 41); and stage III by a single cavity with or without capsule (n = 64). Stage IV was defined as numerous small abscesses scattered all over the liver (n = 6). The results indicate that contrast-enhanced ultrasound is suitable for classifying different stages of pyogenic liver abscesses. Knowledge of the described morphologic patterns influences therapeutic decisions and helps distinguish abscesses from other liver masses.

Analysis of clinical and CT characteristics of patients with Klebsiella pneumoniae liver abscesses: an insight into risk factors of metastatic infection

PURPOSE

To compare the clinical and CT characteristics of patients with Klebsiella pneumoniae liver abscess (KPLA), with or without metastatic infection.

MATERIALS AND METHODS

Clinical information (age, sex, clinical symptoms, underlying disease, hematological parameters, abscess-related mortality) and CT characteristics of abscesses were analyzed to investigate associations with metastatic infection. Metastatic infections were divided into septic pulmonary embolism (SPE) and extra-pulmonary metastatic infection (EMI).

RESULTS

We identified 66 consecutive patients with KPLA. Metastatic infection occurred in 22/66 patients (33.3%); 8/66 (12.1%) patients had SPE, 6/66 (9.09%) patients had EMI; and 8/66 (12.1%) patients had both SPE and EMI. Patients with SPE were younger than patients without SPE (47.7±13.7 y vs.55.6±12.0 y; p=0.03). Unilocular abscess was significantly more common in patients with SPE than the non-SPE group (43.75% vs 18.0%, p=0.036). The mean maximal diameter of EMI was 56.5±21.3 mm and was significantly smaller than that of the non-EMI which was 79.9±31.4 (p=0.011). SPE was significantly associated with development of EMI (50% vs 17.3%, p=0.011).

CONCLUSION

Unilocular liver abscess is associated with SPE, and SPE is strongly associated with EMI among patients with KPLA. A maximal diameter of KPLA<55 mm can be used as a predictor of EMI.

Comparison of pyogenic liver abscesses caused by hypermucoviscous Klebsiella pneumoniae and non-Klebsiella pneumoniae pathogens in Beijing: a retrospective analysis

OBJECTIVE

To perform a retrospective comparison of the clinical and radiological features of Klebsiella pneumoniae (KP)-associated and non-KP-associated pyogenic liver abscesses (PLA) in Chinese patients.

METHODS

Patients with confirmed diagnoses of bacterial liver abscess at three Beijing hospitals were enrolled. Clinical isolates from liver abscesses were used to determine serology and expression of hypermucoviscosity genes. Basic clinical, ultrasonographic (US) and computed tomography (CT) data were recorded and compared between patients with KP- and non-KP-associated PLA.

RESULTS

A total of 101 (77.10%) and 30 (22.90%) cases were due to KP and non-KP pathogens, respectively. Compared with the non-KP cohort, the KP cohort demonstrated a significantly higher incidence of underlying diabetes mellitus, and more gas-forming abscesses, as demonstrated by US and CT examinations. Prior abdominal surgery or chemoradiation therapy was significantly associated with non-KP cases. The non-KP group had a higher chance of a clear edge, compared with the KP group, on pre-contrast CT images.

CONCLUSION

KP and non-KP-associated PLA have distinctive risk factors and unique US and CT features, in Chinese patients.

An elevated gap between admission and A1C-derived average glucose levels is associated with adverse outcomes in diabetic patients with pyogenic liver abscess

OBJECTIVES

To assess whether chronic glycemic control and stress-induced hyperglycemia, determined by the gap between admission glucose levels and A1C-derived average glucose (ADAG) levels adversely affects outcomes in diabetic patients with pyogenic liver abscess (PLA).

METHODS

Clinical, laboratory, and multi-detector computed tomography (MDCT) findings of 329 PLA patients (2004-2010) were retrospectively reviewed. HbA1C levels were used to determine long-term glycemic control status, which were then converted to estimated average glucose values. For the gap between admission glucose levels and ADAG levels, we used receiver operating characteristic (ROC) curve to determine the optimal cut-off values predicting adverse outcomes. Univariate and multivariate logistic regressions were used to identify predictors of adverse outcomes.

RESULTS

Diabetic PLA patients with poorer glycemic control had significantly higher Klebsiella pneumoniae (KP) infection rates, lower albumin levels, and longer hospital stays than those with suboptimal and good glycemic control. The ROC curve showed that a glycemic gap of 72 mg/dL was the optimal cut-off value for predicting adverse outcomes and showed a 22.3% relative increase in adverse outcomes compared with a glycemic gap<72 mg/dL. Multivariate analysis revealed that an elevated glycemic gap≥72 mg/dL was important predictor of adverse outcomes.

CONCLUSIONS

A glycemic gap≥72 mg/dL, rather than admission hyperglycemia or chronic glycemic control, was significantly correlated with adverse outcomes in diabetic PLA patients. Poorer chronic glycemic control in diabetic PLA patients is associated with high incidence of KP infection, hypoalbuminemia and longer hospital stay.

Community-acquired Klebsiella pneumoniae liver abscess: an emerging infection in Ireland and Europe

INTRODUCTION

Klebsiella pneumoniae has emerged as a predominant cause of community-acquired mono-microbial pyogenic liver abscess. This was first described in Taiwan and has been widely reported in Asia. This infectious entity has been described in Europe, with single case reports predominating.

METHODS

We present three cases in one year from our institution in Ireland and review the European literature to date.

RESULTS/CONCLUSION

Klebsiella pneumoniae invasive liver abscess syndrome is now emerging in Europe and notably is not restricted to individuals of Asian descent.

Klebsiella pneumoniae liver abscess: a new invasive syndrome

Klebsiella pneumoniae is a well known human nosocomial pathogen. Most community-acquired K pneumoniae infections cause pneumonia or urinary tract infections. During the past two decades, however, a distinct invasive syndrome that causes liver abscesses has been increasingly reported in Asia, and this syndrome is emerging as a global disease. In this Review, we summarise the clinical presentation and management as well the microbiological aspects of this invasive disease. Diabetes mellitus and two specific capsular types in the bacterium predispose a patient to the development of liver abscesses and the following metastatic complications: bacteraemia, meningitis, endophthalmitis, and necrotising fasciitis. For patients with this invasive syndrome, appropriate antimicrobial treatment combined with percutaneous drainage of liver abscesses increases their chances of survival. Rapid detection of the hypervirulent strain that causes this syndrome allows earlier diagnosis and treatment, thus minimising the occurrence of sequelae and improving clinical outcomes.

Factors associated with treatment failure of percutaneous catheter drainage for pyogenic liver abscess in patients with hepatobiliary-pancreatic cancer

BACKGROUND

The aim of this study was to identify predictors of treatment failure of percutaneous catheter drainage (PCD) in patients with hepatobiliary-pancreatic cancer with pyogenic liver abscess (PLA).

METHODS

Medical records of 44 patients with PLA with underlying hepatobiliary-pancreatic cancer who underwent PCD under computed tomographic guidance as primary treatment between January 2001 and December 2010 were collected and reviewed. Included patients were diagnosed with cholangiocarcinoma (n = 16), hepatocellular carcinoma (n = 12), pancreatic carcinoma (n = 9), carcinoma of the ampulla of Vater (n = 6), and gallbladder cancer (n = 1). The clinical factors related to failure of PCD were determined using logistic regression.

RESULTS

The median age of the 44 patients with PLA was 68 years, and 48% were men. PCD failed in 15 patients (34%). Of the 15 patients with PCD failure, 12 subsequently required surgical intervention because of either clinical deterioration or imaging that demonstrated failure of abscess resolution with PCD. Three of these patients died with the initial drain in place before resolution of the abscess. In patients requiring surgery after PCD failure, the frequency of cure or abscess resolution reached 67%. Fourteen patients (32%) died during hospitalization. Multivariate analysis identified that multiloculated abscesses (P = .005) and abscesses with biliary communication (P = .036) were associated with failure of PCD.

CONCLUSIONS

Multiloculated abscesses and lesions with biliary communication pose a greater likelihood of failure of PCD in patients with hepatobiliary-pancreatic cancer with PLA. Early surgical intervention after PCD failure should be considered for these patients.

Successful hepatectomy for intraperitoneal rupture of pyogenic liver abscess caused by Klebsiella pneumoniae

Klebsiella pneumoniae (KP) is the most common cause of pyogenic liver abscess in eastern Asia. KP liver abscess commonly presents as a single large abscess with a predominantly solid consistency. It is sometimes unsuitable for percutaneous catheter drainage because of the poorly liquefied contents. Antibiotic therapy alone may raise a probability of treatment failure and occurrence of complications such as abscess rupture. Hepatic or portal venous thrombosis, hematogenous spread, and spontaneous rupture also occur frequently. We report a case of KP liver abscess with a typical solid appearance, complicated by disseminated intravascular coagulation, spontaneous rupture, and pyogenic spondylitis.

Clinical outcomes and prognostic factors of cancer patients with pyogenic liver abscess

PURPOSE

Pyogenic liver abscess (PLA) of cancer patients often has a poor prognosis, but corresponding prognostic factors are less investigated. This study aimed to identify predictors of mortality in cancer patients with PLA.

PATIENTS AND METHODS

Medical records of 85 consecutive cancer patients (46 with hepatobiliary pancreatic cancer, 14 with gastrointestinal cancer, and 25 with non-digestive system cancer) having PLA who were admitted to two university hospitals were retrospectively reviewed. The predictors of mortality were determined using Cox regression model.

RESULTS

The overall case fatality rate was 33%. In multivariate analysis, the greater Acute Physiology and Chronic Health Evaluation II score (P = 0.028), multiloculated abscess (P = 0.025), and polymicrobial infection (P = 0.003) were associated with mortality. In subgroup analysis of the 25 patients with multiloculated abscess undergoing percutaneous catheter drainage as primary treatment, the case fatality rates of patients with a solitary smaller abscess (size < 5 cm), those with a solitary larger abscess (size > 5 cm), and those with larger multiple abscesses were 0%, 36%, and 85%, respectively (P = 0.002; using χ (2) for trend).

CONCLUSIONS

The advanced disease stage, multiloculated abscess, and polymicrobial infection posed a greater mortality risk in cancer patients with PLA. Moreover, an early surgical approach should be considered for cancer patients having large, multiloculated complex PLAs.

Liver abscess: an analysis of 183 cases

AIM: To summarize our experience of diagnosis and treatment of liver abscess.

METHODS: The clinical data for 183 patients with liver abscess treated at our hospital from January 2001 to June 2011 were analyzed retrospectively.

RESULTS: Of 183 patients, 152 had single abscess, 31 had multiple abscesses; 107 had diabetes mellitus; 5 had septic shock. The maximal abscess cavity was 139 mm × 115 mm and the smallest was 17 mm × 16 mm. One hundred and seventy-eight cases were treated with conservative intenal medicine and all were cured. Two cases were referred for surgery and three cases were discharged themselves. One hundred and seven cases underwent BUS-guided percutaneous needle aspiration, and the number of needle aspirations ranged from 1 to 7 times.

CONCLUSION: Liver abscess is closely related to diabetes. BUS-guided percutaneous needle aspiration is easy to operate, has good effect, and therefore represents the first choice of treatment for liver abscess.

CT differentiation of pyogenic liver abscesses caused by Klebsiella pneumoniae vs non-Klebsiella pneumoniae

OBJECTIVE

Klebsiella pneumoniae is one of the organisms most commonly isolated from pyogenic liver abscesses in Asian populations. We compared CT findings in liver abscesses caused by K. pneumoniae with those caused by other bacterial pathogens.

METHODS

Of 214 patients with liver abscesses examined over a 5 year period, 129 patients with positive blood or aspirate cultures were enrolled. The patients were divided into two groups: the K. pneumoniae monomicrobial liver abscess (KLA) group (n = 59) and the non-K. pneumoniae monomicrobial or polymicrobial liver abscess (non-KLA) group (n = 70). Two radiologists blinded to the culture results evaluated the CT images, recording the number, size, location and configuration of abscesses, the thickness of the abscess wall, the pattern of rim enhancement, septal enhancement, the double target sign, internal necrotic debris, internal gas bubbles and underlying biliary disease. The presence of diabetes and metastatic infection was also compared between groups. Statistical analyses were performed using univariate (Student's t-test and χ(2) test) and multivariate analyses.

RESULTS

Multivariate analysis showed that a thin wall, necrotic debris, metastatic infection and the absence of underlying biliary disease were the most significant predictors of KLA. When three of the four criteria were used in combination, a specificity of 98.6% was achieved for the diagnosis of KLA.

CONCLUSION

A thin-walled abscess, internal necrotic debris, the presence of metastatic infection and the absence of underlying biliary disease may be useful CT findings in the early diagnosis of K. pneumoniae liver abscesses.

Early diagnosis and therapeutic choice of Klebsiella pneumoniae liver abscess

Nowadays, pyogenic liver abscess (PLA) is still a common and severe intra-abdominal infection, and Klebsiella pneumoniae had emerged as the most common pathogenic bacteria worldwide in the past ten years. Our study aims to achieve an early pathogenic diagnosis and rational therapy modality for Klebsiella pneumoniae liver abscess (KLA) through clinical data analysis. A total of 197 inpatients in Zhongshan Hospital, Shanghai, diagnosed as having liver abscess between March 2001 and September 2009 were enrolled. Patients with monomicrobial infection were divided into two groups: patients with K. pneumoniae liver abscess (KLA group, n=106) and those with non-Klebsiella pneumoniae liver abscess (NKLA group, n=56). A retrospective analysis was made between these two groups on the aspects of underlying diseases, clinical characteristics, laboratory data, culture results, and imaging findings. To evaluate the effects of different medical interventions, monomicrobial KLA patients were further divided into four subgroups (percutaneous liver aspiration, aspiration plus antibiotics flushing, aspiration plus retained catheter, and aspiration plus antibiotics flushing and retained catheter), and corresponding therapeutic effects were analyzed. KLA was more likely to occur in patients with coexisting diseases such as diabetes mellitus (53.77% vs 25.00%, P=0.001) and hepatic adipose infiltration (16.04% vs 5.36%, P=0.029). Compared to NKLA group, clinical characteristics including abdominal pain (40.57% vs 57.14%, P=0.044), hypodynamia (19.81% vs 46.43%, P=0.001), and hepatomegaly (4.72% vs 14.29%, P=0.033) were much milder, but with a higher fasting blood glucose level (7.84±0.36 vs 5.76±0.30, P=0.001) on admission in KLA group. In addition, KLA abscess often appeared singly in the right lobe of the liver with gas forming nature (32.88% vs 13.51%, P=0.039), unsmooth rim (71.23% vs 40.54%, P=0.002), and dynamic septum enhancement (41.10% vs 16.22%, P=0.009). Compared to mono aspiration subgroup, additional antibiotic flushing could not further improve clinical outcomes of KLA patients (P>0.05); however, the retained catheter showed obvious advantage in reducing abscess diameter (34.38±3.25 mm vs 22.67±2.37 mm, P=0.017). It can be concluded that the strong association with diabetes, milder clinical symptoms, and gas-forming nature in CT images makes early pathogenic diagnosis of KLA possible. Comparatively, ultrasonography-guided percutaneous liver aspiration with retained catheter may be the most rational intervention modality of KLA.

Pyogenic liver abscess: Differences in etiology and treatment in Southeast Asia and Central Europe

Knowledge of etiology and timely treatment of underlying causes, when possible, play an important role in the successful therapy of patients with pyogenic liver abscess (PLA). Recent publications from Central Europe and Southeast Asia hint at considerable differences in etiology. In this article, we aim to elaborate these differences and their therapeutic implications. Apart from some special types of PLA that are comparable in Southeast Asia and Central Europe (such as posttraumatic or postprocedural PLA), there are clear differences in the microbiological spectrum, which implies different risk factors and disease courses. Klebsiella pneumoniae (K. pneumoniae) PLA is predominantly seen in Southeast Asia, whereas, in Central Europe, PLA is typically caused by Escherichia coli, Streptococcus or Staphylococcus, and these patients are more likely to be older and to have a biliary abnormality or malignancy. K. pneumoniae patients are more likely to have diabetes mellitus. Control of septic spread is crucial in K. pneumoniae patients, whereas treatment of the underlying diseases is decisive in many Central European PLA patients.

The mysterious case of spontaneous disappearance of hepatocellular carcinoma

We describe the case of a 77-year-old woman with chronic hepatitis C and well compensated cirrhosis in whom a single encapsulated 5.5 cm hepatocellular carcinoma was found in the right liver lobe. The patient was symptomatic with left upper quadrant pain and had elevated alfa-fetoprotein levels (3133 ng/ml). While she was waiting for liver resection and 2 months after the initial diagnosis the pain improved and alfa-fetoprotein levels normalized. A computerized tomography scan showed reduction in size of the lesion to 2.5 cm, with no central arterial enhancement, but with the demonstration of a peripheral rim enhancing in all dynamic phases. Follow up computerized tomography and magnetic resonance imaging examinations showed further reduction in size of the lesion to 1.3 cm with persistence of the enhancing rim 20 months after the initial diagnosis. The spontaneous and durable regression of the HCC and the persistent peripheral enhancing rim could be explained by a strong and persistent activation of the immune system directed against the neoplastic cells.

Liver abscess caused by Klebsiella pneumoniae: two case reports

Introduction

The present case reports highlight the peculiar aspect of Klebsiella pneumoniae liver abscess, an emerging disease in United States and Western countries.

Case presentation

We report two cases of Asiatic patients with Klebsiella-associated liver abscesses evaluated at our institution over a one-year period. Both of them had non-specific clinical symptoms at presentation, a peculiar ultrasonographic appearance and successful treatment with early percutaneous drainage.

Conclusion

Klebsiella related liver abscess is an emerging disease with peculiar clinical features. As compared with other bacterial liver abscesses, Klebsiella pneumonia associated pyogenic liver abscess has distinctive risk factors, unique ultrasonographic and computed tomography features and different prognosis.

Liver abscess caused by Klebsiella pneumoniae: two case reports

Introduction

The present case reports highlight the peculiar aspect of Klebsiella pneumoniae liver abscess, an emerging disease in United States and Western countries.

Case presentation

We report two cases of Asiatic patients with Klebsiella-associated liver abscesses evaluated at our institution over a one-year period. Both of them had non-specific clinical symptoms at presentation, a peculiar ultrasonographic appearance and successful treatment with early percutaneous drainage.

Conclusion

Klebsiella related liver abscess is an emerging disease with peculiar clinical features. As compared with other bacterial liver abscesses, Klebsiella pneumonia associated pyogenic liver abscess has distinctive risk factors, unique ultrasonographic and computed tomography features and different prognosis.

Ruptured hepatic abscess mimicking perforated viscus

BACKGROUND

In the majority of pneumoperitoneum cases we diagnose perforated viscus. We present herein a case of ruptured hepatic abscess mimicking perforated viscus.

CASE REPORT

A 40-year-old man presented to the emergency room with fever and right upper quadrant abdominal pain. The fever had been on/off for a period of 1 month. On physical examination, diffuse abdominal pain with rebounding tenderness was noted. Blood tests showed leukocytosis with left shift, hyperglycemia, and elevated liver function tests. A chest X-ray showed a subdiaphragmatic region air-fluid level, indicating a hepatic abscess. Pneumoperitoneum was also seen. Owing to the status of peritonitis, computed tomography (CT) of the abdomen was performed and revealed an air-containing liver abscess in the right lobe of the liver. Perforation of a hollow organ was also suspected because of the pneumoperitoneum. An emergent laparotomy was immediately performed for the suspicion of a hollow organ perforation. No perforation of the hollow viscus was found. The ruptured hepatic abscess was attributed to the pneumoperitoneum. A blood culture grew Klebsiella pneumoniae four days later, and the same organism was also found in a surgical specimen culture of the abscess.

CONCLUSIONS

For a ruptured hepatic abscess, surgical intervention with draining of the abscess and cleaning of the abdominal cavity are essential to save patient lives.