Gas-forming pyogenic liver abscess: A world review

Clinical characteristics of pyogenic liver abscess with and without biliary surgery history: a retrospective single-center experience

BACKGROUND & AIMS

Pyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS).

METHODS

The study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed.

RESULTS

The percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%).

CONCLUSIONS

Patients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.

Gas Forming Pyogenic Liver Abscess Diagnosed by Point of Care Ultrasound

Gas-forming pyogenic liver abscess (GFLPA) carries a high mortality rate. Early identification of the source of infection in sepsis results in better survival. Bedside point of care ultrasound (POCUS) can be used to help localize a source of infection. A 59-year-old man presented with systemic inflammatory response syndrome (SIRS) and was diagnosed with GFLPA on the initial encounter via clinical assessment and POCUS examination. After commencing antibiotics, optimal glucose control, adequate fluid resuscitation, and early infective source control, he achieved full recovery and was followed up in outpatient medical and surgical clinics. This case illustrates the role of POCUS as a diagnostic tool in sepsis and raises awareness among clinicians to recognize the features of GFLPA on POCUS.

Observational Study of Clinical Profiles and Management of Liver Abscess in Hospitalized Patients: A North Indian Tertiary Care Perspective

Background Liver abscesses are a significant health concern, necessitating prompt diagnosis and appropriate management. Spontaneous liver abscesses are a frequent reason for hospitalizations in India, particularly in the northern part. By analyzing demographics, symptoms, radiological findings, laboratory parameters, and treatment outcomes, this study will contribute valuable insights to enhance the understanding and management of liver abscesses. Aims and objective To evaluate demographic, clinical, laboratory, and radiological parameters and management options in hospitalized patients with liver abscesses at a tertiary care center. Methods This study retrospectively analyzed prospectively collected data from 150 patients diagnosed with liver abscesses who were admitted to our ward for one year. Data on demographic characteristics, clinical presentation, etiology, radiological findings, laboratory investigations, management strategies, and treatment outcomes were collected. Descriptive statistics and relevant statistical tests were employed for data analysis. Results The study population had a mean age of 40.28±12.72 years, with a male preponderance (136 (90.7%)). Amoebic abscesses (94 (62.7%)) were the most common. Hepatomegaly (144 (96%)), fever (140 (93.3%)), abdominal pain (136 (90.7%)), and anorexia (118 (78.7%)) were the most common symptoms. Ultrasonography revealed solitary abscesses (99 (66%)) to be more common than multiple abscesses (24 (16%)), with a predominant location in the right lobe (128 (85.3%)). Laboratory investigations showed leukocytosis in 121 (80.7%), elevated liver enzymes (95 (63.3%) aspartate aminotransferase (AST) and 80 (53.3%) alanine transaminase (ALT)), elevated alkaline phosphatase (ALP) in 133 (88.7%), and low albumin levels (138 (92%)) in a significant proportion of patients. Single-time needle aspiration (95 (63.3%)), percutaneous drain (36 (24%)), and surgical intervention (4 (2.7%)) were the primary treatment modalities. Serum albumin level (p<0.001) and ALP (p<0.001) were significantly low and high, respectively, in patients with hospital stays ≥10 days. Conclusions This study provides insights into patients with liver abscesses' clinical and laboratory parameters and management strategies. The findings highlight the diverse clinical presentation, varied etiologies, and the importance of radiological imaging and laboratory investigations in diagnosis and management. Tailored treatment strategies based on the patient's condition are crucial for optimizing outcomes.

Raptured gas forming pyogenic liver abscess with a biliary fistula in Botswana: a case report

We report a case of gas-forming pyogenic liver abscess (GFPLA) with a ruptured abscess and biliary fistula presenting with peritonitis. The patient had poorly controlled diabetes mellitus and was extremely ill at presentation. The diagnosis was delayed until the abscess ruptured, owing to nonspecific abdominal symptoms at the initial presentation and delayed follow-up radiological investigations. The patient had a high-output biliary fistula post-operatively, which was managed with endoscopic retrograde cholangiopancreatography (ERCP) and stenting with fistula drainage reduction within four weeks. This case highlights the need for follow-up radiological investigations and prompt intervention in patients with diabetes mellitus presenting with fever and vague abdominal pain.

Pneumorrhachis Secondary to Klebsiella pneumoniae Gas-Forming Paraspinal Abscess: A Case report and Review of Literature

Pneumorrhachis is a rare entity, where air pockets are found in the spinal canal and the etiology can be categorized into traumatic and non-traumatic, the latter further categorized into spontaneous, iatrogenic, and associated with infections. Infective causes are often associated with gas-forming organisms and are associated with significant morbidity and mortality. Often the diagnosis is not suspected until imaging is done. We report the case of a 57-year-old man who presented with fever, backache, lower leg weakness, and dysuria. A computed tomography scan for evaluation of intra-abdominal sepsis incidentally showed pneumorrhachis affecting the thoracic and lumbar levels, gas-forming paraspinal abscess, prostate abscess, liver cirrhosis, and sigmoid colon carcinoma. Blood culture isolated Klebsiella pneumoniae. The patient recovered after six weeks of intravenous antibiotics followed later by sigmoid colectomy and chemotherapy. A literature review identified 63 cases of pneumorrhachis associated with infections and can be categorized into infections with spontaneous pneumorrhachis (predominantly respiratory tract infections), infections with pneumorrhachis (predominantly with emphysematous infections), and iatrogenic with infections and pneumorrhachis (predominantly postspinal interventions). Infections with pneumorrhachis occurred in older age groups and were associated with higher mortality compared to the other two categories.

The New Changes of Epidemiology, Etiology, and Clinical Characteristics of Pyogenic Liver Abscesses: A Retrospective Study in a Hospital in Northern China

Purpose

To investigate the epidemiology, etiology, and clinical characteristics of patients with pyogenic liver abscesses (PLA) and provide guidance for clinical treatments.

Patients and Methods

A retrospective study was performed on a cohort of 402 hospitalized patients diagnosed with PLAs at the Affiliated Hospital of Chengde Medical College between January 2016 and December 2021. Patient demographics, drug sensitivity profiles, and microbiological culture results of drainage and blood samples were thoroughly analyzed to identify significant patterns or trends. Furthermore, clinical characteristics and treatments for patients with PLA were comprehensively assessed.

Results

Patients aged 50-69 years had the highest incidence of PLA, accounting for 59.9% of all cases, and 91.5% of them had a fever. Bacterial culture analysis of the 200 patients revealed that Klebsiella pneumoniae (K. pneumoniae) was the most predominant pathogen, detected in 70.5% of cases, exhibiting an upward trend. Escherichia coli (E. coli) was the second most frequently detected pathogen, identified in 14.5% of cases, showing a downward trend. Coexisting diabetes mellitus (DM) was found to be the most common comorbidity for PLA, occurring in most patients with the condition. Patients with a history of abdominal surgery and malignancy had an increased risk for PLA, while those with gallstones had a decreased risk. Drainage combined with antibiotic therapy was identified as the primary treatment of PLA. In addition, multivariate analysis demonstrated that coexisting DM and the presence of gas in the abscess cavity were independent risk factors for septic shock in patients with PLA.

Conclusion

This study reveals a shift in the proportions of pathogens and risk factors in patients with PLA, underscoring the necessity for improved diagnostic and therapeutic strategies.

Giant Klebsiella pneumoniae pyogenic liver abscess in the left liver lobe presenting with dyspepsia and vaginal discharge

Pyogenic liver abscess (PLA) commonly occurs in the right liver lobe, causing the typical symptoms of fever and right upper quadrant pain. Less than one-third of cases occur in the left lobe. We describe an unusual presentation of a giant left-sided PLA that was compressing the stomach and surrounding venous vasculature, causing the respective symptoms of gastro-oesophageal reflux and vaginal discharge from secondary pelvic congestion syndrome. CT revealed a solitary 14 cm×10 cm×10 cm multiloculated lesion, replacing most of the left liver lobe. It was successfully treated with intravenous antibiotics and percutaneous drainage, resulting in complete resolution at 1-year follow-up. This case explores the predisposing risk factor of diabetes in PLA and its association with Klebsiella pneumoniae, which was the offending pathogen in our patient. We also discuss the phenomenon of secondary pelvic venous congestion syndrome and compare similar cases of left-sided PLA, highlighting the different modes of presentation and treatment options.

Clinical and CT comparative study of invasive and non-invasive Klebsiella pneumoniae liver abscesses

AIM

To investigate the clinical and CT features of invasive and non-invasive Klebsiella pneumoniae liver abscesses (KPLA).

MATERIALS AND METHODS

Fifty-one patients with KPLA diagnosis including 26 invasive and 25 non-invasive KPLA cases were analysed retrospectively. All patients underwent routine abdominal unenhanced and three-phase enhanced CT examinations. The CT images were assessed by two experienced radiologists by examining location, number, size, septa, texture, gas in the pus cavity, portal phlebitis, thrombophlebitis, and abnormal perfusion during the arterial phase. Statistical differences for continuous characteristics were analysed with independent samples t-test or Wilcoxon's test, while the chi-square test or Fisher's exact test was used for categorical variables. A logistic regression analysis was performed to determine the independent related factors of invasive KPLA and receiver operating characteristic (ROC) curves were used for assessment.

RESULTS

Age and type 2 diabetes were significantly different between the patients with invasive and non-invasive KPLA. In addition, patients with invasive KPLA had lower levels of platelet and total protein (p<0.05) and higher total bilirubin compared to patients with non-invasive KPLA. Throughout the regression analysis, total bilirubin, platelets, and total protein demonstrated an area under the ROC curves of 0.717, 0.745, and 0.728, respectively.

CONCLUSION

Invasive KPLA occurs predominantly in younger patients with type 2 diabetes. Laboratory tests revealed low platelet and total protein levels and high total bilirubin levels. If the patient with KPLA exhibits hepatic venous thrombophlebitis with no abnormal enhancement around the abscess in the arterial phase of enhanced CT, it indicates that the abscess has invaded.

A complex presentation of an uncommon disease: Gas-forming pyogenic liver abscess complicated by septic pulmonary emboli and muscle abscesses, a case report and review of the literature

Background

Pyogenic liver abscess (PLA) is the most common type of visceral abscess. Its variable clinical presentation depends on patient demography, underlying conditions, causative pathogens as well as the size of the abscess. Most cases are secondary to enteric pathogens that cause focal liver disease. Gas-forming pyogenic liver abscess (GFPLA) is a rare subgroup of PLA characterized by the presence of gas within the abscess. The disease is associated with diabetes mellitus (DM) while Klebsiella penumoniae is the most frequently isolated pathogen. Despite appropriate evaluation and management, secondary complications are common with significant morbidity and mortality that necessitate prompt recognition and management.

Case presentation

We present a case of a 46-year-old gentleman from Bangladesh who presented to the emergency department with fever, chills, and right upper quadrant abdominal discomfort. Evaluation revealed elevated inflammatory markers with high blood glucose and a subdiaphragmatic lucency on a plain chest radiograph. The suspected underlying visceral infection was confirmed by abdominal ultrasonography and computed tomography which demonstrated an emphysematous abscess of 8 cm in diameter in the right liver lobe.Because of clinical instability, the patient was admitted to the medical intensive care unit (MICU) where he received appropriate supportive management with antimicrobials and percutaneous drainage of the abscess. Cultures collected from blood, the abscess, and urine grew a sensitive strain of Klebsiella pneumoniae. During his stay in the MICU, he complained of dyspnea. A CT pulmonary angiography was suggestive of septic emboli. A few days later, the patient started to complain of left gluteal pain and an US revealed a deep left gluteal abscess which required drainage. Cultures of the pus grew the same sensitive strain of Klebsiella pneumoniae. After receiving 6 weeks of parenteral antimicrobial therapy a repeated US revealed complete resolution of the abscess in the liver. Outpatient follow up showed favorable recovery.

Conclusion

Gas-forming pyogenic liver abscess (GFPLA) is a rare manifestation of pyogenic liver abscess that usually occurs in patients with poorly controlled DM. Despite appropriate evaluation, morbidity remains high therefore timely recognition and anticipation of complications is important.

Aging is Associated with Prolonged Hospitalisation Stay in Pyogenic Liver Abscess-A 1:1 Propensity Score Matched Study in Elderly Versus Non-Elderly Patients

BACKGROUND

Mortality of pyogenic liver abscess (PLA) is high ranging 10%-40%. Old age predicts outcomes in many diseases but there is paucity of data on PLA outcomes. We aim to compare the morbidity and mortality between elderly and non-elderly in PLA.

METHODS

This is a retrospective study from 2007-2011 comparing elderly (≥ 65 years old) and non-elderly (< 65 years old) with PLA. A 1:1 propensity score matching (PSM) was performed. Baseline clinical profile and outcomes were compared.

RESULTS

There were 213 patients (elderly patients = 90 [42.3%], non-elderly patients = 123 [57.7%]). Overall median age is 62 (interquartile range [IQR] = 53-74) years old. PSM resulted in 102 patients (51 per arm). Length of hospitalisation stay (LOS) was significantly longer in elderly patients in both unmatched (16 [IQR = 10-24.5] versus 11 [IQR = 8-19] days; P < 0.001) and matched cohorts (17 [IQR = 13-27] versus 11 [IQR = 7-19] days; P = 0.001). In-hospital mortality was significantly higher in elderly patients in the unmatched cohort (elderly patients = 21.1%, non-elderly patients = 7.3%; P = 0.003) but was insignificant following PSM (elderly patients = 15.7%, non-elderly patients = 9.8%; P = 0.219). Duration of antibiotic therapy and need for percutaneous drainage (PD) were comparable before and after PSM.

CONCLUSION

Age ≥ 65 years old is associated with longer LOS. In-hospital mortality though higher in elderly patients, was not statistically significant.

Liver abscess in advanced hepatocellular carcinoma after atezolizumab plus bevacizumab treatment: A case report

RATIONALE

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer globally. Since 2020, combination treatment with atezolizumab and bevacizumab were approved in patients with unresectable HCC in Japan, and atezolizumab plus bevacizumab is the first-line treatment for unresectable HCC.

PATIENT CONCERNS

A 73-year-old Japanese man diagnosed with a large HCC was treated with atezolizumab plus bevacizumab. After 2 cycles, he had fever and fatigue and was admitted to the hospital.

DIAGNOSIS

Abdominal contrast-enhanced computed tomography revealed tumor necrosis in HCC with gas formation in the necrotic area. Laboratory examination revealed a white blood cell (WBC) count of 16,340/μL and C-reactive protein (CRP) level of 33.0 mg/dL. Based on the above findings, he was diagnosed with a liver abscess.

INTERVENTIONS

Percutaneous transhepatic liver abscess drainage and broad-spectrum antibiotics treatment were performed.

OUTCOMES

Despite liver abscess drainage, persistent fever and no improvement in the WBC count or CRP level was observed. The patient's respiratory condition and renal function gradually worsened; The patient's general condition did not improve despite the ventilator support and continuous hemodiafiltration, and he died on day 37.

LESSONS

We report the first case of liver abscess after atezolizumab plus bevacizumab treatment for unresectable HCC.

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.

Metagenome Analysis of the Bacterial Characteristics in Invasive Klebsiella Pneumoniae Liver Abscesses

Background

Klebsiella pneumoniae liver abscess (KPLA) combined with extrahepatic migratory infection (EMI) is defined as invasive KPLA (IKPLA) and is associated with a poor prognosis. The mechanism of IKPLA formation is yet to be elucidated. In this study, metagenomic sequencing was used to compare the bacterial characteristics between IKPLA and KPLA to explore the underlying mechanism of invasiveness.

Methods

Clinical details, imaging, and microbial features were retrospectively evaluated by medical record review. Metagenomic sequencing was performed on the pus samples of liver abscesses whose culture results were indicative of monomicrobial Klebsiella pneumoniae (K. pneumoniae). Bacterial diversity and composition in IKPLA and KPLA were comparatively analyzed, and the key pathways and genes that may affect invasiveness were further explored.

Results

Sixteen patients were included in this study. Five patients with EMI were included in the IKPLA group, and the other eleven patients without EMI were assigned to the KPLA group. There was no statistical difference in the hypermucoviscous phenotype and serotype of K. pneumoniae between the two groups. The bacterial diversity of IKPLA was lower than that of KPLA. The abundant taxa in the IKPLA group were primarily species of unclassified Enterobacteriaceae and K. pneumoniae. The KPLA group had a high abundance of the genera Tetrasphaera and Leuconostoc. Metabolic pathway genes represented most of the enriched genes in IKPLA. Fourteen pathogenic genes with significant differences in abundance were identified between the two groups, including ybtS, fepC, phoQ, acrB, fimK, magA, entC, arnT, iucA, fepG, oqxB, entA, tonB, and entF (p < 0.001).

Conclusion

The diversity and bacterial composition of IKPLA were significantly different from those of KPLA. Microbiological changes in the abscess, activation of the related metabolic pathways, and the pathogenic gene expression may constitute a novel mechanism that regulates the invasiveness of KPLA.

Gas Under Diaphragm: A Rare Case of Ruptured Liver Abscess With Gas Forming Organism

Acute abdominal pain with free air under the diaphragm visible on chest/abdomen X-ray (pneumoperitoneum) is a medical emergency. Most of such cases of pneumoperitoneum are attributable to perforated hollow viscus; however, other possibilities like rupture of liver abscess (by a gas-forming organism) also need to be considered. Further imaging like a CT scan might help in the diagnosis and would also obviate the need for laparotomy in some of such cases. We report a case of acute abdominal pain with gas under the diaphragm due to a ruptured liver abscess caused by Klebsiella pneumoniae. The patient was managed successfully with ultrasound-guided percutaneous aspiration and insertion of a drain along with antibiotics and supportive measures, and no laparotomy was performed.

Emphysematous liver abscess with Edwardsiella tarda infection

This report presents the case of a 51-year-old woman on an immunosuppressant drug and steroids, who presented with general fatigue and was admitted to the intensive care unit. Her serum procalcitonin, lactate, aspartate aminotransferase, and alanine aminotransferase levels and white blood cell counts were elevated. Computed tomography revealed gas formation in her liver, and her culture results revealed Edwardsiella tarda and Escherichia coli infections. She underwent percutaneous transhepatic abscess drainage in addition to antimicrobial administration. She was discharged after 40 days. Cases of emphysematous liver abscess with Edwardsiella tarda infections are rarely reported in the literature and may present in patients with poorly controlled type 2 diabetes. The fatality rate associated with the condition is markedly high.

Differentiating Between an Atypical Hepatic Abscess and Tumor Metastasis Using Magnetic Resonance Imaging and Hepatobiliary Phase Imaging

Objective

To identify diffusion-weighted imaging (DWI) patterns and conspicuity discrepancies on hepatobiliary phase imaging (HBPI) to distinguish atypical hepatic abscesses from hepatic metastases.

Materials and Methods

This retrospective study recruited 31 patients with 43 atypical hepatic abscesses and 32 patients with 35 hepatic metastases who underwent gadobenate dimeglumine-enhanced magnetic resonance imaging. All lesions were confirmed by pathological or clinical diagnosis. For the qualitative and quantitative analyses, the signal intensity, DWI pattern, apparent diffusion coefficient, degree of perilesional edema, perilesional hyperemia, perilesional signal on HBPI, conspicuity, size discrepancy between sequences, contrast-to-noise ratio, signal-to-noise ratio, and relative enhancement ratio on dynamic phases were independently assessed by two radiologists. Significant findings for differentiating the two groups were identified via univariate and multivariate analyses with a nomogram for predicting atypical hepatic abscesses. The interobserver agreement was also analyzed for each variable.

Results

The multivariate analysis revealed that the conspicuity discrepancy (odds ratio [OR] 34.78, 95% confidence interval [CI] 2.09–579.47, p = 0.013) and non-peripheral high signal intensity (SI) rim on DWI (OR 67.46, 95% CI 2.64, 1723.20, p = 0.011) were significant independent factors for predicting atypical hepatic abscesses. They were also shown to be high predictor points on the nomogram. When any of the set criteria were satisfied, 97.7% of atypical hepatic abscesses were correctly identified, with a specificity of 65.7%. When both criteria were combined, the specificity was up to 100%, with a sensitivity of 44.9%.

Conclusion

Conspicuity discrepancy and a non-peripheral high SI rim on DWI are reliable and meaningful features that can distinguish atypical hepatic abscesses from hepatic metastases.

Utility of Acute Physiology and Chronic Health Evaluation (APACHE II) in Predicting Mortality in Patients with Pyogenic Liver Abscess: A Retrospective Study

Pyogenic liver abscess (PLA) is a major life-threatening disease with varied clinical features. This study aimed to determine predictors of mortality in patients with PLA using criteria determined upon admission. We retrospectively examined the data of 324 hospitalized adults in whom liver abscesses were confirmed using abdominal ultrasound and/or computed tomography. The relationship between various risk factors was assessed using multivariate analysis. A total of 109 (33.6%) patients were admitted to the intensive care unit (ICU). The overall mortality rate was 7.4% and was higher among ICU patients than non-ICU patients (21.1% vs. 0.5%, p < 0.001). PLA patients with an Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥18 had a 19.31-fold increased risk, and those with concomitant infections had a 34.33-fold increased risk of 30-day mortality according to multivariate analysis. The estimated area under the receiver operating characteristic curve for predicting 30-day mortality revealed that APACHE II score ≥18 (sensitivity of 75% and specificity of 84%, p < 0.0001) had better discriminative power than Sequential Organ Failure Assessment (SOFA) ≥6 (sensitivity of 81% and specificity of 66%, p < 0.0001). APACHE II has shown better discrimination ability than SOFA in predicting mortality in PLA patients. To improve outcomes in patients with PLA, future management strategies should focus on high-risk patients.

Successful Medical Treatment for Peritonitis Resulting from a Large Pyogenic Liver Abscess Rupture

The rupture of a pyogenic liver abscess (PLA) with peritonitis is a rare occurrence but a surgical emergency with a high mortality rate in the case of gas-forming PLA. Rare cases of ruptured PLA that recovered completely with only medical treatment have been reported. This paper reports a case of a large PLA rupture with peritonitis. In this case, surgical intervention was too risky because of the patient's age and poor general condition. The patient recovered fully with appropriate antibiotic therapy and sufficient percutaneous drainage. Therefore, medical treatment may be considered an alternative option in cases of a ruptured large PLA with peritonitis if surgical intervention is too risky.

A Gas-forming Liver Abscess with Massive Bleeding into the Abscess Cavity Due to a Ruptured Inferior Phrenic Artery

An 88-year-old woman developed a huge abscess, forming an air-fluid level in the right lobe of the liver. A pigtail catheter was placed and drained thick pus with putrid odor from the abscess cavity. Gram-positive rods were detected in the pus, which were subsequently determined to be Clostridium perfringens by culture. She developed hemorrhaging in the abscess cavity when the right inferior phrenic artery was damaged by inflammation that had spread from the abscess. Emergency transarterial embolization with gelatin sponges was performed, and the bleeding ceased. We herein report a rare case of liver abscess that caused inferior phrenic artery injury, resulting in bleeding.

Outcomes of Gas-Forming Pyogenic Liver Abscess Are Comparable to Non-Gas-Forming Pyogenic Liver Abscess in the Era of Multi-Modal Care: A Propensity Score Matched Study

Background: Gas-forming pyogenic liver abscess (GFPLA) occurs in 7%-24% of all PLAs and has been associated traditionally with high mortality rates. Studies have suggested that the use of a proactive approach of prompt resuscitation, parenteral antibiotic agents, percutaneous drainage, and a dedicated multi-disciplinary team may improve clinical outcomes. Hence, we aim to investigate whether the clinical outcomes of PLA are determined by gas formation. Methods: This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes mellitus, presence of septic shock, hemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Baseline demographics, clinical profile, and peri-operative data were compared. Results: There were 213 patients who had PLA: 41 (19.2%) patients had GFPLA and 172 (80.8%) patients had non-GFPLA. The PSM analysis resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Median duration of parenteral antibiotic agents was significantly lower in the GFPLA group (9.5 d vs. 14 d, p = 0.044), but median total duration of antibiotic use was comparable (GFPLA 39 d vs. non-GFPLA 37 d, p = 0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs. 15, p = 0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36 (72.2%) vs. 47/72 (65.3%), respectively, p = 0.467) and in-hospital all-cause death (4/36 (11.1%) vs. 7 (9.7%), p = 0.822) Conclusions: Outcomes of GFPLA are comparable to those of non-GFPLA in the era of multi-modal care.

Clinical Features and Prognosis of Gas-Forming and Non-Gas-Forming Pyogenic Liver Abscess: A Comparative Study

Background: Gas-forming pyogenic liver abscess (GFPLA) accounts for up to 30% of all pyogenic liver abscess (PLA) cases. However, little is known of the differences in clinical features and prognosis between GFPLA and non-GFPLA. Aim: This retrospective study compared the clinical features and prognosis of GFPLA and non-GFPLA. Patients and Methods: Data for 392 patients with PLA treated from January 1, 2007 to December 31, 2016 were reviewed. Gas-forming pyogenic liver abscess was defined as gas in the abscess. Liver abscesses were considered non-GFPLA (n = 326) or GFPLA (n = 66). The clinical features and outcomes of patients with GFPLA were compared with that of patients without GFPLA. Results: The groups were similar in gender ratio, age, smoking, drinking, and comorbidities. Klebsiella pneumoniae was the most common pathogenic bacteria, but the negative rate of bacterial culture of the non-GFPLA group was higher than that of the GFPLA. In etiologies, the GFPLA group had more biliary source infection and less cryptogenic infection. In addition, the GFPLA group had a higher rate of previous hepatobiliary surgery, especially biliary enteric anastomosis. Compared with the non-GFPLA group, the percentage of the GFPLA group with antibiotic agents combined with percutaneous drainage was higher, whereas the percentages given antibiotic agents alone and antibiotic agents combined with surgical drainage were lower. Patients with GFPLA had higher rates of sepsis and pleural effusion, and longer hospital stays than did non-GFPLA patients. No patient died during hospitalization. Conclusions: The GFPLA group had more biliary source infection and less cryptogenic infection in etiologies. Gas-forming pyogenic liver abscess is associated with past hepatobiliary surgery, especially biliary enteric anastomosis and has high rates of sepsis and long hospitalization. Thus, the patients with PLA with a history of hepatobiliary surgery should be monitored more closely in the early stage of the PLA. It needs to be recognized as a distinct clinical entity.

Effect of diabetes mellitus on short-term prognosis of 227 pyogenic liver abscess patients after hospitalization

BACKGROUND

Pyogenic liver abscess (PLA) is an inflammatory disease with increasing incidence. When it occurs with diabetes mellitus (DM), the risk of recurrence and mortality may increase. However, the effect of DM on the short-term prognosis of PLA patients after hospitalization remained unknown.

METHODS

Two hundred twenty-seven PLA patients who received treatment at the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to January 2018 were retrospectively enrolled. They were divided into two groups as the DM group (n = 61) and the Non-DM group (n = 166). In the DM group, HbA1C level < 7% was considered to be good-control of glycaemia (n = 23). The clinical characteristics and overall short-term survival were analyzed.

RESULTS

The proportion of PLA patients with DM was 26.87%. In the DM group, there was a higher incidence of hypertension and Candida spp. infection. Conservative administration and percutaneous drainage were mainly used in patients with good- (60.87%) and poor-control (60.53%) of glycaemia, respectively. During follow-up, 24 (10.57%) died due to uncontrolled systemic infections and other serious complications. Compared with PLA patients without DM, patients in the DM group had significantly increased 6-month mortality rate after discharge (Log-Rank test, P = 0.021). Poor-control of glycaemia did not reduce the six-month survival, while the recurrence rate of PLA within 3 months showed an almost 3-fold increase (13.16% vs. 4.35%). Further multivariate analyses found that DM was the only independent risk factor for the PLA six-month survival (odds ratio [OR]: 3.019, 95% confidence interval [CI]: 1.138-8.010, P = 0.026). However, the blood glucose level had no significant effect on the short-term survival of PLA patients with DM (Log-Rank test, P = 0.218).

CONCLUSIONS

In PLA patients, DM aggravated short-term mortality and blood glucose levels should be well controlled.

Prognostic nomogram for the combination therapy of percutaneous catheter drainage and antibiotics in pyogenic liver abscess patients

PURPOSE

To identify the predictors for recovery of pyogenic liver abscess (PLA) patients treated with percutaneous catheter drainage (PCD) and antibiotics, and then develop an effective nomogram to predict the recovery time.

MATERIALS AND METHODS

The retrospective study included consecutive PLA patients treated with PCD and antibiotics. We defined the overall recovery time (ORT) as the time from the PCD procedure to the time of clinical success or failure. Based on the ORT, its predictors were identified with univariate and multivariate analyses. Then, a nomogram was developed to predict the ORT, and was internally validated by using Harrell's c statistic.

RESULTS

A total of 116 patients and 142 PCD procedures with a median ORT of 15.0±10.6 days were included. Gas-formation (GF; HR: 0.486 [95% CI 0.312-0.757]; P = 0.001), diabetes mellitus (DM; HR: 0.455 [95% CI 0.303-0.682]; P<0.001), and preinterventional septic shock (PSS; HR: 0.276 [95% CI 0.158-0.483]; P < 0.001) were identified as predictors for the ORT of combination therapy after univariate and multivariate analyses, which indicated a significantly longer ORT than those patients without. The prognostic analyses demonstrated that the more predictors (GF, DM, and PSS) a patient exhibited, the longer ORT for the combination therapy. A nomogram was developed to predict the ORT and revealed high accuracy, with Harrell's c statistic of 0.73.

CONCLUSION

GF, DM, and PSS were predictors for the recovery of PLA patients treated with PCD and antibiotics. The nomogram was effective in predicting the ORT of combination therapy.

Ruptured Pyogenic Liver Abscess with Pneumoperitoneum 19 Years After Pancreatoduodenectomy

BACKGROUND Rupture of a pyogenic liver abscess is rare but serious complication. In patients after pancreatoduodenectomy, there are some conditions causing the development of liver abscesses (e.g., chronic reflux-cholangitis, efferent jejunal loop stasis, stenosis of the biliary anastomosis, and pancreatogenic diabetes). However, the number of published cases of liver abscess after pancreatoduodenectomy is small. CASE REPORT A 42-year-old male was admitted with severe abdominal pain, fever, and jaundice. Nineteen years previously, he had undergone pancreatoduodenectomy and cholecystectomy for chronic pancreatitis with obstructive jaundice. Two years later, diabetes mellitus was diagnosed, with subsequent insulin treatment. At admission, symptoms of peritonitis were present. Plain abdominal radiography showed free gas under the right hemidiaphragm and heterogeneous liver shade with small gas-fluid levels. The rupture of a liver abscess was suspected. Laparotomy with adhesiolysis, debridement of the liver abscess cavity, and abdominal drainage were performed. The postoperative period was complicated by sepsis, right lower lobe pneumonia, and two-sided pleural effusions, on the background of insulin-dependent diabetes and malnutrition. The patient was discharged on the 40th day and the subdiaphragmatic drains were removed on the 114th day. Sixteen months after surgery, the patient's condition was satisfactory. Magnetic resonance imaging and echography showed the absence of biliary hypertension. The liver tissue had healed completely. CONCLUSIONS A unique case of ruptured liver abscess after pancreatoduodenectomy is presented. To the best of our knowledge, this is the first published case with such a long time interval (19 years) between pancreatoduodenectomy and the formation of a pyogenic liver abscess.

Prospective case-control analysis of the aetiologies of acute undifferentiated fever in Vietnam

Acute undifferentiated fever (AUF) is frequently observed in tropical settings, but diagnosing the cause of AUF is often a challenge for local physicians and the physicians treating returning travellers. We conducted a case-control study in central Vietnam in 2016. A total of 378 febrile adult patients (AUFs) with a fever for ≤21 days, no evidence of localized infection and negative screening tests for dengue and malaria, and 384 afebrile adult patients (Controls) were prospectively enrolled. Whole blood, plasma, eschar swab, throat swab and urine specimens were collected and analysed. Quantitative PCR and RT-PCR were used to test for 55 bacteria, viruses and their subtypes. Serological tests were also used to test for rickettsial agents. The most common aetiology was influenza virus (20.9% in AUFs vs. 0% in Controls), followed by rickettsial agents (mainly Orientia tsutsugamushi and Rickettsia typhi) (10.8% vs. 0.3%), dengue virus (7.7% vs. 0.5%), Leptospira (4.8% vs. 0.8%), adenovirus (4.8% vs. 1.0%), and enterovirus (2.1% vs. 0%) (p < .05). The real proportion of dengue in AUF cases was underestimated because patients with dengue-positive rapid diagnosis tests were excluded from the study. The emerging agent Rickettsia felis, which had not been previously observed in Vietnam, was detected in this study. In total, 216 patients (57.1%) were given causative diagnoses, comprising 143 (66.2%) monoinfections and 73 (33.8%) coinfections. The infections caused by these agents should be considered in clinical practice and further studies. Additionally, agents susceptible to doxycycline were detected in 15.6% of AUFs; thus, this drug should be included in the panel used to treat AUF patients.