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Datta P, Rattan D, Sharma D, Sharma N, Kalra N, Duseja A, Angrup A, Sehgal R. Novel diagnostic approach for amoebic liver abscess using cell free (cf) DNA: a prospective study. Infect Dis (Lond) 2024; 56:259-267. [PMID: 38112684 DOI: 10.1080/23744235.2023.2294119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Amoebic liver abscess (ALA) is commonly seen in tropical countries and diagnosis of ALA relies mainly on non-specific serological and imaging techniques as well as PCR from pus. OBJECTIVE This study evaluated the potential of using cell free DNA (cfDNA) from serum and urine for diagnosing ALA. METHODS We prospectively evaluated quantitative PCR (qPCR) for detection of cf DNA in serum and urine sample in all liver abscess patients. The samples were collected from patients reporting to emergency ward of Postgraduate Institute of Medical Education and Research, Chandigarh, India with symptoms suggestive of liver abscess. Real time PCR was done to detect cf DNA in serum and urine by targeting 99-bp unit of small subunit rRNA of Entamoeba histolytica and conventional PCR for pus. RESULTS A total 113 samples (serum and urine) and 100 pus samples were analysed. A total of 62 ALA patients were confirmed; with maximum 57 patients detected by qPCR for cfDNA in the serum, 55 patients by PCR on pus aspirate and 50 ALA patients by qPCR for cfDNA in urine sample. Therefore, the sensitivity of qPCR for detection of cf DNA in serum was 91.94% and for urine was 80.65%. CONCLUSION A total of 11.2% of ALA patients were diagnosed only through detection of E. histolytica cf DNA in their serum and urine. Detection of cfDNA from serum, urine of ALA has a potential role in future especially for developing countries as it is a rapid, sensitive and patient friendly diagnostic approach.
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Affiliation(s)
- Priya Datta
- Department of Medical Parasitology, PGIMER, Chandigarh, India
| | - Divya Rattan
- Department of Medical Parasitology, PGIMER, Chandigarh, India
| | - Devyani Sharma
- Department of Medical Parasitology, PGIMER, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, PGIMER, Chandigarh, India
| | - Archana Angrup
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Rakesh Sehgal
- Department of Medical Parasitology, PGIMER, Chandigarh, India
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Dumic I, Caetano EM, Domingues SM, Pantic I, Radovanovic M, Prada LR, Nordstrom CW, Antic M, Milovanovic T, Kotseva M, Singh A, Fnu S. Clinical characteristics, diagnosis, treatment, and outcome of patients with liver abscess due to Aspergillus spp: a systematic review of published cases. BMC Infect Dis 2024; 24:345. [PMID: 38519916 PMCID: PMC10960385 DOI: 10.1186/s12879-024-09226-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/14/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Aspergillus spp liver abscess is a relatively rare entity and thus far no systematic review has been performed examining patients' demographics, clinical manifestations, diagnosis, management, and outcome. METHODS We performed a systematic review of the literature using MEDLINE and LILACS databases. We searched for articles published in the period from January 1990 to December 24, 2022, to identify patients who developed liver abscesses due to Aspergillus spp. RESULTS Our search yielded 21 patients all of whom had invasive aspergillosis confirmed on liver biopsy. Of these patients 81% were adults, and 60% were males. The majority (86%) of patients were immunocompromised and 95% had symptomatic disease at the time of diagnosis. The most common symptoms were fever (79%), abdominal pain (47%), and constitutional symptoms (weight loss, chills, night sweats, fatigue) (38%). Liver enzymes were elevated in 50%, serum galactomannan was positive in 57%, and fungal blood cultures were positive in only 11%. Co-infection with other pathogens preceded development of apsergillosis in one-third of patients, and the majority of the abscesses (43%) were cryptogenic. In the remaining patients with known source, 28% of patients developed liver abscess through dissemination from the lungs, 19% through the portal vein system, and in 10% liver abscess developed through contiguous spread. The most common imaging modality was abdominal computerized tomography done in 86% of patients. Solitary abscess was present in 52% of patients while 48% had multiple abscesses. Inadequate initial empiric therapy was prescribed in 60% of patients and in 44% of patients definite treatment included combination therapy with two or more antifungal agents. Percutaneous drainage of the abscesses was done in 40% of patients, while 20% required liver resection for the treatment of the abscess. Overall mortality was very high at 38%. CONCLUSION Further studies are urgently needed for a better understanding of pathophysiology of liver aspergillosis and for developement of newer blood markers in order to expedite diagnosis and decrease mortality.
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Affiliation(s)
- Igor Dumic
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA.
| | | | | | - Ivana Pantic
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Radovanovic
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Libardo Rueda Prada
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Hospital Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Charles W Nordstrom
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Marina Antic
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Tamara Milovanovic
- Clinic for Gastroenterology and Hepatology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Magdalena Kotseva
- Internal Medicine Residency Program, Franciscan Health, Olympia Fields, IL, USA
| | - Amteshwar Singh
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Shweta Fnu
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
- Department of Infectious Diseases, Mayo Clinic Health System, Eau Claire, WI, USA
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Kumar S, Arun N, Dev A. Comparative Incidence of Pyogenic and Amoebic Liver Abscesses in Trauma and Emergency Patients at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna: A One-Year Observational Study. Cureus 2024; 16:e51615. [PMID: 38313880 PMCID: PMC10837101 DOI: 10.7759/cureus.51615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Liver abscesses, particularly pyogenic and amoebic types, pose a significant healthcare challenge, especially in developing countries. Accurate differentiation and effective treatment of these abscess types are crucial in emergency medical settings. This study aims to analyze the incidence, clinical characteristics, and treatment outcomes of pyogenic and amoebic liver abscesses in a trauma and emergency department setting. METHODS Conducted at the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, this one-year observational study involved 100 patients diagnosed with liver abscesses. The study employed a comprehensive approach, examining incidence rates, demographic trends, clinical presentations, treatment modalities, and outcomes, including recurrence rates. RESULTS The study observed a higher incidence of pyogenic liver abscesses, accounting for 60% of cases (n=60), compared to amoebic liver abscesses, which constituted 40% (n=40). In terms of demographics, pyogenic liver abscesses were more prevalent among older males, with the average age being 48 years, and 70% (n=42) of the patients were male. In contrast, amoebic liver abscess patients had an average age of 42 years, with 60% (n=24) being male. Key clinical findings revealed that pyogenic liver abscess cases (n=60) had higher white blood cell counts and elevated liver enzyme levels than those with amoebic liver abscesses (n=40). The treatment outcomes indicated high success rates for both types of liver abscesses. Pyogenic liver abscesses had a success rate of 90% (n=54), while amoebic liver abscesses showed a slightly higher success rate at 95% (n=38). However, there was a notable difference in recurrence rates: pyogenic liver abscesses had a recurrence rate of 8.3% (n=5), whereas amoebic liver abscesses had a lower recurrence rate of 2.5% (n=1). The logistic regression analysis conducted to identify potential predictors of treatment success did not reveal any statistically significant factors across both types of liver abscesses. CONCLUSION The study highlights a higher incidence of pyogenic liver abscesses in an urban Indian healthcare setting and the complexity of predicting treatment outcomes based on demographic and clinical factors. The findings emphasize the need for nuanced clinical approaches and vigilant post-treatment monitoring, especially for pyogenic liver abscesses. They also underscore the importance of further research to explore additional variables influencing liver abscess treatment outcomes.
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Affiliation(s)
- Sumeet Kumar
- Surgery (Trauma and Emergency), Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Nitali Arun
- Microbiology, Radha Devi Jageshwari Memorial Medical College and Hospital, Muzaffarpur, IND
| | - Anand Dev
- Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
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Patel S, Southall C, Varghese R. Multifocal hepatic abscess post-ERCP. BMJ Case Rep 2023; 16:e256578. [PMID: 38114294 DOI: 10.1136/bcr-2023-256578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
A woman in her 40s presented to hospital with cholangitis. A magnetic resonance cholangiopancreatography showed a moderately dilated common bile duct and mild intrahepatic duct dilatation with sludge. She underwent a successful endoscopic retrograde cholangiopancreatography (ERCP) and sphincteroplasty. She subsequently developed recurrence of fevers and abdominal pain with rising inflammatory markers. Initial investigations and imaging were unremarkable. A positron emission tomography scan demonstrated multiple fluorodeoxyglucose (FDG)-avid hepatic lesions, and subsequent imaging confirmed multifocal liver abscesses without a drainable collection. The patient was managed with intravenous co-amoxiclav initially before switching to oral antibiotics, however, represented 1 week later with similar symptoms. Her antibiotic coverage was broadened to intravenous pipercillin-tazobactam, and she was discharged on this with follow-up in clinic. This case report highlights the rare complication of hepatic abscesses following ERCP and the importance of considering this as a differential in patients who present with sepsis following the procedure.
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Affiliation(s)
- Samit Patel
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Clea Southall
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
| | - Roy Varghese
- General Medicine, Armadale Health Service, Armadale, Western Australia, Australia
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Dauny V, Dioguardi-Burgio M, Leflon-Guibout V, Bert F, Roux O, Houzé S, Lefort A, Rossi G. [Clinical and radiological differences between amoebic and pyogenic liver abscess: A case-control study]. Rev Med Interne 2023; 44:472-478. [PMID: 37105864 DOI: 10.1016/j.revmed.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/06/2023] [Accepted: 03/29/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Amoebic liver abscess (ALA) is the fourth cause of mortality by parasitic infection. This study aimed to assess clinical, radiological and therapeutic characteristics of patients admitted for amoebic liver abscess compared to pyogenic abscess in a French digestive tertiary care-centre. MATERIAL AND METHOD The charts of patients hospitalized for a liver abscess between 2010 and 2020 were retrospectively assessed then separated in two groups: amoebic liver abscess and pyogenic liver abscess from portal underlying cause. Clinical and radiological data were collected for univariate comparison. RESULTS Twenty-one patients were hospitalized during the time of the study for ALA, and 21 patients for pyogenic liver abscess with a portal mechanism. All patients hospitalized for ALA lived in and/or had travelled recently in an endemic area. In comparison with patients hospitalized for pyogenic abscess, patients admitted for ALA were younger (44years old vs. 63years old, P<0.001), had less comorbidities (5% vs. 43% of patients with at least one comorbidity, P<0.01), a longer median duration of symptoms (10days vs. 3days, P=0.015), abdominal pain (86% vs. 52%, P=0.019), and a slighter leucocytosis (9600G/L vs. 15,500G/L, P=0.041) were more frequent. On the abdominal tomodensitometry, density of ALA was higher (34 vs. 25 UH, P<0.01), associated with a focal intra-hepatic biliary dilatation and less often multiloculated. CONCLUSION While rare in western countries, amoebic liver abscess care should not be underestimated. The presence of a solitary liver abscess of intermediate density on computed tomography, occurring on a patient returning from an endemic zone should lead the physician to a possible diagnosis of ALA.
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Affiliation(s)
- Vincent Dauny
- Service de médecine interne, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France.
| | - Marco Dioguardi-Burgio
- Service de radiologie, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France; Inserm U1149, « centre de recherche sur l'inflammation » (CRI), université Paris Cité, 75018 Paris, France
| | - Véronique Leflon-Guibout
- Laboratoire de microbiologie, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France
| | - Frédéric Bert
- Laboratoire de microbiologie, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France
| | - Olivier Roux
- Service d'hépatologie, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France
| | - Sandrine Houzé
- Service de parasitologie, hôpital Bichat, AP-HP, 75018 Paris, France; IRD, MERIT, université Paris Cité, 75006 Paris, France
| | - Agnès Lefort
- Service de médecine interne, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France; Inserm, IAME, UMR1137, université Paris Cité, Paris, France
| | - Geoffrey Rossi
- Service de médecine interne, hôpital Beaujon, groupe hospitalier AP-HP Nord, université Paris Cité, Clichy, France
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Usuda D, Tsuge S, Sakurai R, Kawai K, Matsubara S, Tanaka R, Suzuki M, Takano H, Shimozawa S, Hotchi Y, Tokunaga S, Osugi I, Katou R, Ito S, Mishima K, Kondo A, Mizuno K, Takami H, Komatsu T, Oba J, Nomura T, Sugita M. Amebic liver abscess by Entamoeba histolytica. World J Clin Cases 2022; 10:13157-13166. [PMID: 36683647 PMCID: PMC9851013 DOI: 10.12998/wjcc.v10.i36.13157] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/01/2022] [Accepted: 12/08/2022] [Indexed: 12/26/2022] Open
Abstract
Amebic liver abscesses (ALAs) are the most commonly encountered extraintestinal manifestation of human invasive amebiasis, which results from Entamoeba histolytica (E. histolytica) spreading extraintestinally. Amebiasis can be complicated by liver abscess in 9% of cases, and ALAs led to almost 50000 fatalities worldwide in 2010. Although there have been fewer and fewer cases in the past several years, ALAs remain an important public health problem in endemic areas. E. histolytica causes both amebic colitis and liver abscess by breaching the host’s innate defenses and invading the intestinal mucosa. Trophozoites often enter the circulatory system, where they are filtered in the liver and produce abscesses, and develop into severe invasive diseases such as ALAs. The clinical presentation can appear to be colitis, including upper-right abdominal pain accompanied by a fever in ALA cases. Proper diagnosis requires nonspecific liver imaging as well as detecting anti-E. histolytica antibodies; however, these antibodies cannot be used to distinguish between a previous infection and an acute infection. Therefore, diagnostics primarily aim to use PCR or enzyme-linked immunosorbent assay to detect E. histolytica. ALAs can be treated medically, and percutaneous catheter drainage is only necessary in approximately 15% of cases. The indicated treatment is to administer an amebicidal drug (such as tinidazole or metronidazole) and paromomycin or other luminal cysticidal agent for clinical disease. Prognosis is good with almost universal recovery. Establishing which diagnostic methods are most efficacious will necessitate further analysis of similar clinical cases.
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Affiliation(s)
- Daisuke Usuda
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Shiho Tsuge
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Riki Sakurai
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Kenji Kawai
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Shun Matsubara
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Risa Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Makoto Suzuki
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Hayabusa Takano
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Shintaro Shimozawa
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Yuta Hotchi
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Shungo Tokunaga
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Ippei Osugi
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Risa Katou
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Sakurako Ito
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Kentaro Mishima
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Akihiko Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Keiko Mizuno
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Hiroki Takami
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Takayuki Komatsu
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
- Department of Sports Medicine, Faculty of Medicine, Juntendo University, Bunkyo 113-8421, Tokyo, Japan
| | - Jiro Oba
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
| | - Manabu Sugita
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima 177-8521, Tokyo, Japan
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Priyadarshi RN, Kumar R, Anand U. Amebic liver abscess: Clinico-radiological findings and interventional management. World J Radiol 2022; 14:272-285. [PMID: 36160830 PMCID: PMC9453321 DOI: 10.4329/wjr.v14.i8.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/30/2022] [Accepted: 06/20/2022] [Indexed: 02/08/2023] Open
Abstract
In its classic form, amebic liver abscess (ALA) is a mild disease, which responds dramatically to antibiotics and rarely requires drainage. However, the two other forms of the disease, i.e., acute aggressive and chronic indolent usually require drainage. These forms of ALA are frequently reported in endemic areas. The acute aggressive disease is particularly associated with serious complications, such as ruptures, secondary infections, and biliary communications. Laboratory parameters are deranged, with signs of organ failure often present. This form of disease is also associated with a high mortality rate, and early drainage is often required to control the disease severity. In the chronic form, the disease is characterized by low-grade symptoms, mainly pain in the right upper quadrant. Ultrasound and computed tomography (CT) play an important role not only in the diagnosis but also in the assessment of disease severity and identification of the associated complications. Recently, it has been shown that CT imaging morphology can be classified into three patterns, which seem to correlate with the clinical subtypes. Each pattern depicts its own set of distinctive imaging features. In this review, we briefly outline the clinical and imaging features of the three distinct forms of ALA, and discuss the role of percutaneous drainage in the management of ALA.
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Affiliation(s)
- Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, Patna 801507, Bihar, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna, Patna 801507, Bihar, India
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Meister P, Irmer H, Paul A, Hoyer DP. Therapy of pyogenic liver abscess with a primarily unknown cause. Langenbecks Arch Surg 2022; 407:2415-2422. [PMID: 35635587 PMCID: PMC9467942 DOI: 10.1007/s00423-022-02535-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
Purpose Pyogenic liver abscess (PLA) is a collection of pus in the liver, often without a known direct cause. There is discord on the best diagnostic and therapeutic strategy. We aimed to examine these questions in our patient cohort. Methods A total of 66 out of 309 patients with PLA at our tertiary referral center between 2012 and 2020 had a primarily unknown cause. We analyzed PLA configuration, comorbidities, and whether an underlying cause could be found later. Therapy was sorted by antibiotics alone, percutaneous drainage, and primary surgery. Success was assessed by a change of initial therapy, in-hospital mortality, and mean hospital stay. Results Overall mortality was 18%; in 55%, a causative condition could be found. CRP, GGT, size, and multiple localization go along with higher mortality. Antibiotics alone had a failure rate of 82%. Percutaneous drainage was successful in 70% of cases. Surgery was mainly reserved for failed previous non-surgical treatment and had in-hospital mortality of 12%. Conclusions PLA goes along with high mortality. In the majority of all patients, a causative condition can be identified by detailed diagnostics. Percutaneous drainage together with antibiotics is the therapy of choice and is successful in 70% of cases. If drainage is insufficient or impossible, surgery is an effective alternative.
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Rossi G, Nguyen Y, Lafont E, Rossi B, Canouï E, Roux O, Dokmak S, Bert F, Fantin B, Lefort A. Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses. Infection 2022; 50:1205-1215. [PMID: 35316531 DOI: 10.1007/s15010-022-01793-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Pyogenic liver abscess (PLA) is a severe disease, which unfavourable evolution remains frequent. Our objective was to assess predictive factors of unfavourable outcome in patients with PLA. METHODS We conducted a retrospective study in a French tertiary care centre. All patients admitted for PLA between 2010 and 2018 were included. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence of PLA after an initial cure, or death within 3 months after diagnosis. Hazard ratios (95% CI) were calculated with multivariable Cox proportional hazard models. RESULTS 302 patients were included among which 91 (30.1%) patients had an unfavourable outcome because of PTF, recurrence or death in 55 (18.2%), 28 (9.2%) and 32 (10.6%) patients, respectively. Hepatic metastases (HR 2.08; 95% CI 1.04-4.15), a nosocomial infection (2.25; 1.14-4.42), portal thrombosis (2.12; 1.14-3.93), and the isolation of Enterococcus spp. (2.18; 1.22- 3.90) were independently associated with PTF. Ischemic cholangitis (6.30; 2.70-14.70) and the isolation of Streptococcus spp. (3.72; 1.36-10.16) were associated with the risk of recurrence. Charlson comorbidity index (HR 1.30 per one point; 95% CI 1.15-1.46; p < 0.001), portal thrombosis (3.53; 1.65-7.56) and the presence of multi-drug-resistant organisms (3.81; 1.73-8.40) were associated with mortality within 3 months following PLA diagnosis. PLA drainage was the only factor associated with a lower mortality (0.14; 0.06-0.34). CONCLUSION Identification of specific risk factors may help to improve the management of PLA and to elaborate targeted recommendations according to patient's and disease's characteristics.
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Affiliation(s)
- Geoffrey Rossi
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Yann Nguyen
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Emmanuel Lafont
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Benjamin Rossi
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
- Service de Médecine Interne, Hôpital Robert Ballanger, 93600, Aulnay-sous-bois, France
| | - Etienne Canouï
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Olivier Roux
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Safi Dokmak
- Service de Chirurgie Viscérale Et Digestive, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Frédéric Bert
- Service de Microbiologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Bruno Fantin
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France
- Service de Médecine Interne, Hôpital Robert Ballanger, 93600, Aulnay-sous-bois, France
| | - Agnès Lefort
- Service de Médecine Interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
- IAME, UMR1137, Université de Paris and INSERM, Paris, France.
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Detection of Entamoeba histolytica and bacterial etiological agents in patients with clinically suspected cases of liver abscesses. J Parasit Dis 2022; 46:254-261. [PMID: 35299900 PMCID: PMC8901831 DOI: 10.1007/s12639-021-01435-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022] Open
Abstract
Liver abscess is one of the conditions having multiple etiological agents. It can be parasitic or can be due to bacterial among other causes. Entamoeba histolytica is one of the common protozoan parasites causing amoebic liver abscess. So, accurate diagnosis is important for proper management and treatment. We have tried to detect the various bacterial etiological agents along with Entamoeba histolytica using culture of bacteria and polymerase chain reaction for E. histolytica in suspected liver abscess cases. Liver aspirates/pus collected from 63 patients were subjected to bacterial gram staining and culture along with wet mount and PCR for E. histolytica. Patients' clinical details and outcomes were also noted and co-related.It was seen that 22 (34.9%) out of 63 samples showed the presence of bacteria by gram staining whereas aerobic bacterial growth was seen in 28.6% and only 1.6% in anaerobic culture. Amoebic liver abscess showed E. histolytica in 36 patients out of 63 study participants (57.1%) by PCR. The study showed that 44.4% of patients had a habit of alcohol consumption and 19.1% were chronic smokers. Abdominal pain (90.3%) was the most common presenting feature followed by fever (64.5%). The most common co-morbidities in the enrolled patients was diabetes mellitus (19.3%) and least with chronic liver disease (3.2%). Liver abscess, a multi-etiological condition needs a robust diagnostic method. Just a single method or a single sample type is not sufficient to diagnose, as it may miss out other causes. Treating its associated co-morbidities may help to lessen it.
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11
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A Multicenter Retrospective Study on Clinical Characteristics and Outcome of Pyogenic Liver Abscess Focusing Multidrug-Resistant Organisms. J Clin Med 2022; 11:jcm11041114. [PMID: 35207386 PMCID: PMC8874681 DOI: 10.3390/jcm11041114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/12/2022] [Accepted: 02/17/2022] [Indexed: 02/04/2023] Open
Abstract
The emergence of multidrug-resistant organisms (MDROs) is a growing problem worldwide. However, little is known about the incidence, clinical features and outcomes of pyogenic liver abscesses (PLAs) caused by MDROs. A retrospective study of 833 patients with PLA admitted from 2008 to 2017 was performed. MDROs were found in 55 (6.6%) patients, and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae was the most common causative microorganism. To evaluate the clinical features of and risk factors for MDRO-induced PLAs, propensity score matching (PSM) was performed in a 1:3 ratio (55 patients with MDROs and 165 patients without MDROs). After PSM, previous hepatobiliary procedure, preadmission exposure to antibiotics and elevated alkaline phosphatase levels were independent risk factors for MDRO-induced PLA. Sixteen patients (7.3%) died during hospitalization. Admission to intensive care unit (ICU), inadequate initial antibiotic treatment and use of inotropic agents were factors predictive of mortality. Although the presence of MDROs was not associated with in-hospital mortality, inadequate initial antibiotic treatment was prescribed to a large portion of the patients with MDRO-induced PLAs. We conclude that initial empirical antibiotic therapy for PLA should be based on the possibility of infection with MDROs, and close monitoring is necessary for patients with risk factors for in-hospital mortality.
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12
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Liver Abscesses in Tropics. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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13
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Losie JA, Lam JC, Gregson DB, Parkins MD. Epidemiology and risk factors for pyogenic liver abscess in the Calgary Health Zone revisited: a population-based study. BMC Infect Dis 2021; 21:939. [PMID: 34507537 PMCID: PMC8431851 DOI: 10.1186/s12879-021-06649-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/28/2021] [Indexed: 12/20/2022] Open
Abstract
Background Pyogenic liver abscess (PLA), although uncommon in North America, is associated with significant morbidity and mortality. We sought to re-examine the epidemiology, risk factors, and outcomes of PLA in a large, diverse Canadian health zone. Methods All Calgary Health Zone (CHZ) residents aged ≥20 with PLA between 2015 and 2017 were identified. Incidence and mortality rates were calculated using census data. Risk factors for PLA were identified using a multivariate analysis. Data was compared to 1999–2003 data, also collected in the CHZ. Results There were 136 patients diagnosed with PLA between 2015 and 2017. Incidence rate during this period increased significantly relative to 1999–2003 (3.7 vs 2.3 cases/100,000 population, p < 0.01), however, mortality rates remained similar. The microbiological composition of PLA did not change over this 15-year time period but the number of antimicrobial resistant isolates did increase (8% vs 1%, p = 0.04). The greatest risk factors for PLA relative to general populations included current malignancy, liver-transplant, end-stage renal disease, and cirrhosis. Thirty-day mortality was 7.4% and independent risk factors included polymicrobial bacteremia, absence of abscess drainage, congestive-heart failure, a history of liver disease, and admission bilirubin. Conclusions Pyogenic liver abscess is a health concern with rising incidence rate. The increasing prevalence of comorbidities in our population and factors that are associated with risk of PLA suggests this will continue to be an emerging diagnosis of concern. Increasing prevalence of antibiotic resistant organisms compounding unclear optimal treatment regimens is an issue that requires urgent study.
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Affiliation(s)
- Jennifer A Losie
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Department of Medicine, University of Calgary, Calgary, Canada
| | - John C Lam
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Daniel B Gregson
- Department of Medicine, University of Calgary, Calgary, Canada.,Alberta Provincial Laboratories, Calgary, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
| | - Michael D Parkins
- Department of Medicine, University of Calgary, Calgary, Canada. .,Department of Microbiology and Infectious Diseases, Calgary Zone Alberta Health Services, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
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14
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Peters L, Burkert S, Grüner B. Parasites of the liver - epidemiology, diagnosis and clinical management in the European context. J Hepatol 2021; 75:202-218. [PMID: 33636243 DOI: 10.1016/j.jhep.2021.02.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/22/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
Parasites in the liver cause significant global morbidity and mortality, as they can lead to recurrent cholangitis, cirrhosis, liver failure and cancer. Due to climate change and globalisation, their incidence is increasing, especially in Europe. The correct diagnosis of a hepatic parasite is often delayed because clinicians are unfamiliar with respective entities. Therefore, in this review, we aim to provide clinicians with a comprehensive clinical picture of hepatic parasites and to bring these neglected parasitic liver diseases to the wider attention of hepatology stakeholders in Europe and around the world.
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Affiliation(s)
- Lynn Peters
- University Hospital of Ulm, Department of Internal Medicine III, Division of Infectious Diseases, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Sanne Burkert
- University Hospital of Ulm, Department of Internal Medicine III, Division of Infectious Diseases, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Beate Grüner
- University Hospital of Ulm, Department of Internal Medicine III, Division of Infectious Diseases, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
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15
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Mousa H, Al-Bluwi GSM, Al Drini ZFM, Gasmelseed HI, Alkoteesh JA, Babiker ZOE. Importation of Entamoeba histolytica and predominance of Klebsiella pneumoniae in liver abscesses: a 7-year retrospective cohort study from the United Arab Emirates. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2021; 7:17. [PMID: 34118991 PMCID: PMC8196433 DOI: 10.1186/s40794-021-00140-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/10/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is a dearth of information on liver abscesses in the United Arab Emirates. Herein, we describe the clinical features of liver abscesses and determine their incidence rates and clinical outcomes. METHODS We retrospectively reviewed the clinical charts of adult patients with a primary diagnosis of liver abscess at a major hospital over a 7-year period. RESULTS Amongst 45 patients, 82.2% (37/45) had a pyogenic liver abscess (PLA) and 17.8% (8/45) had amoebic liver abscesses (ALA). Overall, patients were young (median age 42 years, IQR 35-52), mostly males (77.8%, 35/45) from the Indian subcontinent (55.6%, 25/45), presented with fever (88.9%, 40/45) and abdominal pain (88.9%, 40/45), and had a solitary abscess on imaging (71.1% (32/45). Crude annual incidence rates were 35.9/100,000 hospital admissions (95% CI 26.2-48.0) and 5.9/100,000 inhabitants (95% CI 4.3-7.9). All ALA patients were from the Indian subcontinent (100%, 8/8). Klebsiella pneumoniae was the most frequent pathogen in PLA (43.2% [16/37], 95% CI 27.1-60.5%). The hospital stay was shorter in ALA (7.5 days, IQR 7-8.5) than in PLA (14 days, IQR 9-17). No deaths were recorded within 30 days of hospitalisation. CONCLUSIONS ALA was exclusively seen in migrants from the Indian subcontinent, suggesting importation. Further research to characterise K. pneumoniae isolates and assess potential risk factors is needed.
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Affiliation(s)
- Hussam Mousa
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.,Surgical Institute, Al Ain Hospital, Al Ain, United Arab Emirates
| | - Ghada Salameh Mohammed Al-Bluwi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Zainab Fathi Mohammed Al Drini
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | | | | | - Zahir Osman Eltahir Babiker
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates. .,Division of Infectious Diseases, Al Ain Hospital, Al Ain, United Arab Emirates. .,Present Address: Division of Infectious Diseases, Sheikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi, United Arab Emirates.
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16
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Inaba Y, Izawa N, Ishikawa M, Yamamiya A, Hoshi K, Arisaka T, Majima Y, Tominaga K, Iijima M, Goda K, Irisawa A. Huge Amoebic Liver Abscess in the Left Lobe Treated by Oral Administration of Metronidazole. Intern Med 2020; 59:3023-3026. [PMID: 32727992 PMCID: PMC7759695 DOI: 10.2169/internalmedicine.5301-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A man in his 60s visited a clinic with chief complaints of a fever and general malaise. Suspecting a liver abscess in the left lobe with infiltration into the subcutaneous fat tissue under the rectus abdominis muscle based on computed tomography findings, we performed fine-needle aspiration. An amoebic liver abscess was diagnosed. Remission was achieved by the oral administration of metronidazole alone without placement of a drainage tube. The results obtained in this case suggest that the first line of treatment should be a non-invasive approach with oral administration alone. Invasive intervention should then be considered depending on subsequent progress.
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Affiliation(s)
- Yasunori Inaba
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Naoya Izawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Mutsumi Ishikawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Akira Yamamiya
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Koki Hoshi
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Takahiro Arisaka
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Yuichi Majima
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Makoto Iijima
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Kenichi Goda
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Japan
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Entamoeba histolytica DNA Detection in Serum from Patients with Suspected Amoebic Liver Abscess. J Clin Microbiol 2020; 58:JCM.01153-20. [PMID: 32759355 DOI: 10.1128/jcm.01153-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/01/2020] [Indexed: 12/23/2022] Open
Abstract
Amoebic liver abscess (ALA) is regularly seen in travelers or immigrants from tropical countries. The diagnosis relies on liver imaging that is not specific and on the detection of anti-Entamoeba histolytica antibodies, which cannot distinguish an acute from a former infection. We tested whether E. histolytica DNA detection in serum can improve the diagnosis of ALA. We retrospectively tested available serum samples taken from patients with ALA and non-ALA space-occupying lesions of the liver between 1 January 2010 and 30 November 2019. The quantitative PCR (qPCR) assay tested specifically amplifies a 99-bp fragment of the small-subunit rRNA gene of E. histolytica We analyzed 76 samples (19 ALA and 57 non-ALA samples) collected from 76 patients within 6 days before and after the antiamoebic treatment. Serum qPCR results were positive for 17 of 19 ALA patients and for none of the control patients (sensitivity and specificity were 89.5% and 100%, respectively). In parallel, the sensitivity and specificity of anti-E. histolytica antibody detection were 100% and 89.5%, respectively. The two false-negative qPCR results may be explained by ongoing metronidazole treatment or a possible persistent seropositivity that was not caused by the current liver abscess. Additionally, of 12 abscess pus aspirates (5 from ALA and 7 from non-ALA samples) tested, 5 were qPCR positive and 7 were qPCR negative, with concordant results in serum. This study demonstrates that cell-free circulating E. histolytica DNA can be detected in serum in ALA. This may assist in both positive diagnoses and treatment efficacy follow-up. The origin of this circulating DNA remains to be investigated.
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Guo Y, Qin X, Chen S, Liu X, Gu P. Diagnosis efficacy of CEUS for hepatic inflammatory lesions. J Clin Lab Anal 2020; 34:e23231. [PMID: 32017229 PMCID: PMC7307339 DOI: 10.1002/jcla.23231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose In this study, the efficacy of US/CEUS and clinicopathologic parameters in differential diagnosis of hepatic inflammatory lesions were evaluated. Methods This was a retrospective study in which CEUS imaging was performed on 182 patients. Among these patients, 44 patients had hepatic inflammatory lesions and 138 patients had malignant lesions. The ultrasound (US), CEUS, and clinicopathologic parameters with respect to differential diagnosis of hepatic inflammatory lesions were analyzed. Results Irregular lesion shape and unclear margin were commonly seen in hepatic inflammatory lesions by US/CEUS examination. Hypoenhancement in arterial phase (AP) and portal venous phase (PVP), and isoenhancement in delayed phase (DP) were more commonly found in inflammatory lesions rather than malignant lesions [9% (4/44), 68% (30/44), and 16% (7/44) vs 2% (3/138), 11% (15/138), 1% (1/138), respectively; P < .05]. The enhancement coverage was also a significant indicator for the differentiation of inflammatory lesions and malignant lesions (P < .05). History of hepatitis or cirrhosis, and higher serum alpha‐fetoprotein (AFP) level were indicators for malignant lesions, while liver parasites and higher body temperature were indicators for inflammatory lesions. When the US/CEUS findings were combined with clinicopathologic parameters, the diagnostic accuracy of inflammatory lesions could reach 93.3%, with sensitivity, specificity, positive predictive value, and negative predictive value of 63.64%, 96.03%, 84.85%, and 88.32%, respectively. Conclusion The US/CEUS findings combined with clinical characteristics can accurately differentiate hepatic inflammatory lesions and malignant lesions. The results of study will improve the diagnostic confidence for hepatic inflammatory lesions.
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Affiliation(s)
- Yuanyuan Guo
- Department of Gynaecology and ObstetricsAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
| | - Xiachuan Qin
- Department of UltrasoundNanchong Central HospitalSichuanChina
| | - Shaoxian Chen
- Radiology DepartmentGaoping District People Hospital of NanchongNanchongChina
| | - Xuebin Liu
- Department of UltrasoundNanchong Central HospitalSichuanChina
| | - Peng Gu
- Department of UltrasoundAffiliated Hospital of North Sichuan Medical CollegeNanchongChina
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