Liver abscess of children in Côte-d’Ivoire: retrospective analysis of a series of 30 cases

Pediatric Liver Abscess: Outcomes of Protocol-based Management and Predictors of Poor Outcome

BACKGROUND

Liver abscess (LA) is an important cause of morbidity in children, especially in tropical countries. There is a paucity of data in pediatric LA with no standard guidelines regarding the best modality of treatment and drainage. With a large influx of patients at our center and protocol-based management; we aimed to study clinic-radiologic profile, risk factors, complications and outcomes of children with liver abscess and assessed possible predictors for poor outcomes.

MATERIALS AND METHODS

This retrospective observational study was conducted from January 2019 to September 2019 at a tertiary care hospital in India. Records of all children (<12 years of age) with ultrasonographically diagnosed liver abscess were accessed for clinic-radiological and demographic profile, laboratory investigations, treatment, complications and outcomes. Patients were categorized into favorable or unfavorable groups based on predefined criteria and were compared for possible predictors of poor outcomes. Outcomes for the protocol-based management were analyzed.

RESULTS

There were 120 cases of pediatric liver abscess with a median age of 5 years at presentation. The commonest clinical features were fever (100%) and pain in the abdomen (89.16%). The majority of liver abscesses were solitary (78.4%) and in the right lobe (73.3%). Malnutrition was present in 27.5%, overcrowding for 76.5% of patients and worm infestation in 2.5% of patients. Age-related leukocytosis (P = 0.004), neutrophilia (P = 0.013), elevated Aspartate transaminase (P = 0.008), elevated alanine transaminase (P = 0.007) and hypoalbuminemia (P = 0.014) were significantly more in the unfavorable group. Overall, 29.2% of patients underwent conservative management with antibiotics alone, 25.0% underwent percutaneous needle aspiration (PNA), 49.1% underwent ultrasound-guided percutaneous drain (PCD) insertion and open surgical drainage (OSD) was needed in a single patient. The success rate was 100% for conservative management, 76.6% for PNA, 94.7% for PCD and 100% for OSD with an overall mortality of 2.5%.

CONCLUSIONS

Age-related leukocytosis, neutrophilia, elevated aspartate transaminase or alanine transaminase and hypoalbuminemia at presentation are predictors of poor outcomes in pediatric liver abscess. Protocol-based management leads to the appropriate use of PNA and PCD while decreasing mortality and morbidity related to either.

Parasite-Induced Th2 Polarization—An Unusual Cause of Paediatric Hepatic Abscess

Liver abscess (LA) is a serious infectious disease, but is relatively rare in the paediatric population, especially in developed countries. Mostly, hepatic abscesses are pyogenic, caused by Staphylococcus aureus, while in extremely rare cases can be caused by parasites, such as Ascaris lumbricoides. Antimicrobial therapy and percutaneous drainage are the treatments of choice, lowering the mortality caused by this infection. We report a case of a 3-year-old girl admitted to the hospital for abdominal pain and a low-grade fever, with abdominal ultrasonography revealing a hepatic lesion. Initial laboratory tests showed moderate anaemia, thrombocytosis, eosinophilia, high inflammatory markers, and normal liver function. A computed tomography scan revealed two liver abscesses located subdiaphragmatically, and a high immunoglobulin E (IgE) value (22,300 U/mL). After excluding other possible etiologies, the patient was tested for parasitic infections. IgE for Ascaris lumbricoides came slightly higher. In addition to empirical antibiotic treatment, the patient received albendazole and made an uneventful recovery, with the full remission of the abscesses and without the need for drainage. In certain cases, parasites such as Ascaris lumbricoides are capable of inducing a T helper 2 (Th2) dominated immune response, predisposing the host to eosinophilia, hyperIgE, and increased susceptibility to bacterial infections. Early diagnosis and treatment in these cases may lead to less invasive therapy options in order to obtain a full recovery. To the best of our knowledge, this is the only reported case in the literature of a paediatric patient with parasite-induced liver abscesses, with extremely high IgE values, minimal symptomatology, that made a fast, full recovery without the need of drainage.

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.

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.