Infectious Hepatic Cyst: An Underestimated Complication

Diagnosing Infectious Hepatic Cysts in an Older Patient With Multiple Skin Masses: A Case Report

Among the most severe complications of hepatic cystic diseases is infectious hepatic cysts (IHCs). IHCs may appear mainly among immunocompromised hosts. However, older patients have a variety of immunological conditions. The detection of the factors suppressing immunity is essential for patients with IHCs. Herein, we present the case of an 86-year-old woman admitted to the emergency department with a fever. We suspected IHCs based on changes in abdominal ultrasound findings. After multiple follow-ups to determine the cause of the fever that was unresponsive to treatment, we discovered debris in the cyst that had not been present at the time of the initial presentation. The patient was subsequently treated with percutaneous transhepatic drainage and tazobactam/piperacillin. The investigation of the causes of immunosuppression clarified the multiple skin masses. The biopsy of the mass clarified diffuse large B cell lymphoma without lymph node swellings. Consecutive ultrasound can detect findings missed during the initial presentation and changes that occur within a short period. The detection of the causes of immunosuppression is essential even among older patients with IHCs for better care among older patients.

EASL Clinical Practice Guidelines on the management of cystic liver diseases

The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.

Repeated bacteremia and hepatic cyst infection lasting 3 years following pancreatoduodenectomy: A case report

BACKGROUND

Simple hepatic cysts are commonly occurring lesions that are usually asymptomatic and require no treatment. Hepatic cyst infection, however, is considered a severe complication. We report a case of hepatic cyst infection following pancreatoduodenectomy with repeated fever lasting for almost 3 years, and two cysts were infected successively.

CASE SUMMARY

A 72-year-old woman diagnosed with adenocarcinoma of duodenal papilla underwent pancreatoduodenectomy with Child reconstruction. She then suffered repeated occurrences of bacteremia and hepatic cyst infection for 3 years. Blood cultures were positive for Klebsiella pneumoniae and Escherichia coli a total of 7 times and 4 times, respectively. During the early stage, we suspected that postoperative reflux cholangitis was the cause of fever and bacteremia. Multiple cysts were observed, so it was difficult to determine which cyst was infected. Through repeat examination, we found the focus of infection, and we treated the patient with antimicrobials and performed percutaneous cyst drainage. The patient did not experience another cyst infection for more than 4 years.

CONCLUSION

Biliary reconstruction inducing hepatic cyst infection is easily misdiagnosed as biliary reflux infection, Repeated imaging examination is a method for identifying the infected focus.

The Persistent Approach to Diagnose Infectious Hepatic Cysts in a Patient With Recurrent Fever: A Case Report

Diagnosing infectious hepatic cysts (IHCs) can be challenging. Moreover, patients with IHCs may present with various symptoms. Diagnosis of IHCs can be even more difficult in patients with multiple liver cysts. For appropriate diagnosis, the detection of infectious sections in the liver is essential. However, diagnosing and determining definite treatments for patients with IHCs can be particularly challenging when they have polycystic liver disease. We present a case of a 70-year-old man who visited a rural community hospital with a primary complaint of recurrent fever and pain in the right upper quadrant. Based on his clinical history, physical examination findings, and imaging findings after three admissions, he was diagnosed with IHCs. This case demonstrates the challenges in diagnosing IHCs in patients with multiple hepatic cysts and highlights the necessity of a careful follow-up of clinical histories and findings of definitive imaging tests in the diagnosis of IHCs in patients with recurrent fever. To diagnose IHCs effectively, a comprehensive approach including history taking, physical examination, and diagnostic testing, is essential. IHCs should be considered by physicians when patients present with recurrent fever. To avoid missing IHCs, physicians in outpatient departments should continuously follow up on patients’ IHC-related symptoms such as fever and right upper quadrant pain.

Infected hepatic cyst complicating urinary sepsis

Congenital hepatic cysts are a common disorder. Usually they are asymptomatic and do not have to be treated. However, some serious complications can occur. We report here the case of an 86-year old patient who has been treated by a percutaneous drainage for an infected solitary hepatic cyst due to urinary sepsis. She was admitted to the Department of Internal Medicine for epigastric pain with fever and chills. The patient was treated for a urinary tract infection 3 weeks ago by her General Practitioner. On admission, blood tests showed 21 620 neutrophils per microliter with a C-reactive protein level at 443.7 mg/L, procalcitonin > 200 ng/mL, total bilirubin at 1.43 mg/dL, lactate dehydrogenase at 666 U/L and alanine aminotransferase at 227 U/L. Urinalysis and hemocultures highlighted the presence of Escherichia coli and Streptococcus constellatus. The abdominal tomodensitometry indicated the presence of a left hepatic biliary cyst with banal appearance. She was first treated with intravenous amoxicillin clavulanic acid. After a few days, another abdominal tomodensitometry with contrast pinpointed a large abscess of 11 centimeters in diameter extending to liver segments II and IV with a similar small lesion in segments IV and V. clindamycin per os was added to the treatment because of its good diffusion in tissues. Percutaneous drain was inserted under tomodensitometric control and stayed in place until the follow-up at three weeks. Bacteriologic culture on the fluid sample demonstrated the presence of Escherichia coli and Streptococcus constellatus. The abscess completely regressed after 6 weeks of treatment and the biologic abnormalities resolved at the same time.

Huge solitary-infected liver cyst successfully managed by deroofing operation to remove 3.8 l of pus

Simple liver cysts are usually asymptomatic, and complications are uncommon. However, infection of cysts can very occasionally occur, and this troublesome complication requires treatment. An 87-year-old woman admitted for dyspnea, abdominal discomfort, fever, and mild icterus underwent ultrasonographic (US) and computed tomography (CT) examinations, and a huge cystic lesion was identified in the right hepatic lobe. The diagnosis of an infected gigantic liver cyst was made by abdominal CT and percutaneous transhepatic drainage under ultrasonographic guidance. The pus viscosity was so high that pus drainage was ineffective. Bacterial culture was positive for Klebsiella pneumoniae. The cyst diameter was approximately 21 cm, and the total pus discharge was 3.8 l. Emergency operation to fenestrate the cyst wall relieved the patient's critical condition. This report is clinically significant because 3.8 l of pus may be one of the largest reported quantity of drained pus from an infected cyst. We found no reports of > 3.8 l of drained pus in an English literature search. It is also very rare that imaging identified postoperative liver regeneration filling the huge empty space previously occupied by the cyst. Large liver cysts in older people should be carefully followed, preparing for the rare possibility of infection.