Gas-Forming Pyogenic Liver Abscess with Septic Shock. Case Rep Crit Care. 2015;2015:632873. [PMID: 26090240 PMCID: PMC4458291 DOI: 10.1155/2015/632873]

Clostridium perfringens Liver Abscess Disguised as Biliary Disease: A Report of Two Cases and a Review of the Literature

Liver abscesses caused by Clostridium perfringens are rare but rapidly fatal. In only a few days, patients progress from liver abscess to sepsis, intravascular hemolysis, multiple organ failure, and even death. These abscesses often occur in patients after trauma or surgery or in those with immunodeficiency. Because patients only show non-specific symptoms such as fever and abdominal pain in the early stage, they can easily be misdiagnosed and miss the therapeutic window, resulting in a poor prognosis. The diagnosis of Clostridium perfringens liver abscess mainly depends on computed tomography (CT), needle aspiration, and/or blood culture. After diagnosis, treatments such as antibiotic therapy, surgical abscess drainage, blood transfusion as needed, and correction of metabolic disturbances must be immediately administered to prevent severe complications. Here, we present two cases of liver abscess due to Clostridium perfringens infection. Both patients initially presented only with fever, abdominal pain, and jaundice, symptoms that were easily confused with cholangitis caused by cholelithiasis. The patients then progressed rapidly and, despite receiving antimicrobial and multimodal sepsis treatment, both eventually died of multiple organ dysfunction syndrome. Clinicians should be on high alert for Clostridium perfringens liver abscesses disguised as biliary disease. Early diagnosis and treatment with the appropriate antibiotics and surgery are fundamental for the survival of the affected patients.

Ruptured Emphysematous Liver Abscess: An Unusual Presentation in Kochs

Gas forming liver abscess (GFLA) though rare is seen in diabetic patients. Rupture of such abscesses usually requires surgical intervention. These cases are associated with high morbidity and mortality due to sepsis. Tuberculous liver abscesses are more often silent in presentation. GFLA formed in the background of a tuberculous liver abscess is rare. We present a case of ruptured GFLA with underlying tuberculous pathology in a normoglycemic patient. The abscess was managed by image guided intervention. A brief case report along with review of literature is presented.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Clostridium paraputrificum septicemia and liver abscess

We report the first case of a healthy 23-year-old female who underwent an interventional radiology-guided embolization of a hepatic adenoma, which resulted in a gas forming hepatic liver abscess and septicemia by Clostridium paraputrificum. A retrospective review of Clostridial liver abscesses was performed using a PubMed literature search, and we found 57 clostridial hepatic abscess cases. The two most commonly reported clostridial species are C. perfringens and C. septicum (64.9% and 17.5% respectively). C. perfringens cases carried a mortality of 67.6% with median survival of 11 h, and 70.2% of the C. perfringens cases experienced hemolysis. All C. septicum cases were found to have underlying liver malignancy at the time of the presentation with a mortality of only 30%. The remaining cases were caused by various Clostridium species, and this cohort’s clinical course was significantly milder when compared to the above C. perfringens and C. septicum cohorts.

Microwave ablation of liver metastasis complicated by Clostridium perfringens gas-forming pyogenic liver abscess (GPLA) in a patient with past gastrectomy

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GPLA is one rare complication of liver microwave ablation.

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It can be diagnosed with CT scan which shows gas-containing infective focus.

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Patients with gastrectomy may have an increased risk of such infection due to gut flora change.

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To date, data on effectiveness of empirical antibiotic is not convincing.

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Close monitoring following ablation should be prioritised to allow timely intervention and prevent escalation of infection.

Introduction

Gas-forming pyogenic liver abscess (GPLA) caused by C. perfringens is rare but fatal. Patients with past gastrectomy may be prone to such infection post-ablation.

Presentation of case

An 84-year-old male patient with past gastrectomy had MW ablation of his liver tumors complicated by GPLA. Computerised tomography scan showed gas-containing abscess in the liver and he was managed successfully with antibiotic and percutaneous drainage of the abscess.

Discussion

C. perfringens GPLA secondary to MW ablation in a patient with previous gastrectomy has not been reported in the literature. Gastrectomy may predispose to such infection. Even in high-risk patients, empirical antibiotic before ablation is not a standard of practice. Therefore following the procedure, close observation of patients’ conditions is necessary to allow early diagnosis and intervention that will prevent progression of infection.

Conclusion

Potential complication of liver abscess following MW ablation can never be overlooked. The risk may be enhanced in patients with previous gastrectomy. Early diagnosis and management may minimise mortality and morbidity.

Effects of dopamine, norepinephrine and dobutamine on gastric mucosal pH of septic shock patients

The effect of different vasoactive drugs on the pH [intracellular pH (pHi)] of gastric mucosa in patients with septic shock was evaluated in the present study. According to the vasoactive drugs applied, 48 patients with septic shock were divided into 3 groups: A, B and C, with 16 cases each. Cases of group A were treated with dopamine, those of group B with norepinephrine while those of group C were treated with norepinephrine plus dobutamine. The changes of pH of gastric mucosa were observed before treatment (baseline) and 6, 12, 24 and 48 h after treatment, and the hemodynamic indicators were observed before treatment (baseline) and 6 h after administration. The gastric mucosal pH was not significantly different between two of the three groups before treatment (each at P>0.05). The gastric mucosal pH of group A did not change 6, 12, 24 and 48 h after treatment with drugs compared with the baseline (all at P>0.05), while the gastric mucosal pH in groups B and C were each statistically higher at the time points of 6, 12, 24 and 48 h after treatment with drugs compared with the respective baselines (all at P<0.05). Following treatment with drugs, the gastric mucosal pH of group C at all the time points of 6, 12, 24 and 48 h after treatment were significantly higher than those of groups A and B at the same time points after treatment, while there were some statistical differences between groups A and B at these time points (6, 12, 24 and 48 h after treatment; P<0.05). The hemodynamic indicators of the patients before treatment were not significantly different between two of the three groups (all at P>0.05). Compared with the baseline values, the mean arterial pressure and the cardiac index of each group after treatment were significantly increased, the pulmonary capillary wedge pressure and the central venous pressure of groups B and C significantly increased (all at P<0.05) and the heart rate of group A was significantly increased (P<0.05). In conclusion, the gastric mucosal pH of the septic shock patients was increased when treated with norepinephrine or with dobutamine. Additionally, the gastric mucosal pH was significantly higher when the patients were treated with dobutamine and norepinephrine in combination than with norepinephrine or dopamine alone. Dopamine, norepinephrine and dobutamine can improve the systemic hemodynamic conditions in patients with septic shock.