Imaging-guided percutaneous needle aspiration or catheter drainage of neonatal liver abscesses: 14-year experience

Hepatic abscess due to Candida species in neonates: Case reports in Vietnam

Neonatal hepatic abscess (NHA) is a fatal condition in neonates. NHA can be caused by many organisms including bacteria, parasites, and fungi. Fungal NHA is a rare but troublesome cause in terms of diagnosis and treatment. We present three cases of fungal NHA caused by Candida. In these three cases, different underlying problems associated with NHA had been found.

Pediatric Hepatic Cystic Lesions: Differential Diagnosis and Multimodality Imaging Approach

When a pediatric hepatic cystic lesion is identified at imaging, the differential diagnosis may be broad, including developmental, infectious, neoplastic, and posttraumatic or iatrogenic causes. The location of a cystic lesion and its number, size, composition, and relationship to the biliary system are features that help in narrowing the differential diagnosis. An incidentally detected simple hepatic cyst is the most commonly encountered. Ciliated foregut cysts are typically located in hepatic segment IVa. The presence of multiple cysts should raise suspicion for fibropolycystic liver disease, a group of related lesions-including biliary hamartoma and choledochal cyst-caused by abnormal embryologic development of the ductal plate. Communication of the cystic lesion with the biliary tree can confirm the diagnosis of choledochal cyst. In a neonate with jaundice, a cystic lesion at the porta hepatis should raise suspicion for choledochal cyst versus cystic biliary atresia. Hepatic abscess can appear cystlike, though typically with internal contents. In an immunocompromised child, multiple cystlike lesions should raise concern for fungal microabscesses. A complex cystic mass in a young child should raise suspicion for mesenchymal hamartoma, which can evolve into undifferentiated embryonal sarcoma if untreated. Hepatic hematoma and biloma can appear cystlike in children with a history of trauma or recent intervention. In neonates with an umbilical vein catheter (UVC), an intrahepatic cyst along the course of the UVC should raise concern for infusate extravasation. Familiarity with imaging findings and clinical features is essential for achieving accurate diagnosis of pediatric hepatic cystic lesions, which in turn can guide appropriate clinical management. Online supplemental material is available for this article. ^©RSNA, 2022.

Streptococcus gallolyticus subspecies pasteurianus causing early onset neonatal sepsis complicated by solitary liver abscess in a preterm infant

Streptococcus gallolyticus ssp pasteurianus (SGp) is an uncommon but increasingly recognized cause of neonatal sepsis and meningitis. Liver abscess in neonates is extremely rare. But liver abscess due to SG has never been reported in the literature. We present the first case of liver abscess due to SGp in a late preterm infant. A female infant was born at 36 weeks via normal vaginal delivery to a mother with unremarkable antenatal history. She had progressively worsening respiratory distress since birth and was intubated at 13 h of life. One dose of surfactant was delivered and ventilation continued. Parenteral crystalline Penicillin and Gentamicin were initiated and her blood culture at birth grew SGp. She had a spike of fever on day 5 of life. An ultrasound (US) scan of the abdomen was included in the septic work up. A multi-septated cystic liver abscess was noted in the right lobe of the liver. As there was inadequate response to appropriate intravenous antibiotics, needle aspiration and biopsy were performed on day 35 of life. Aspirate was sterile and histopathology confirmed a liver abscess. The patient continued to be treated with antibiotics for 8 weeks with serial US scans of the liver showing resolution of the abscess. Increasing awareness among paediatric and neonatal fraternity about these new emerging bacterial infections can facilitate early diagnosis and treatment.

Liver abscess in early infancy with no underlying risk factors: a case series

Liver abscess in early infancy is uncommon, needs a high index of suspicion for diagnosis and carries a high mortality. It presents most frequently by a fulminant course, generalised sepsis and multiple metastatic abscesses. An underlying predisposing factor is usually attributed in nearly all cases reported to date. These include prematurity, low birth weight, umbilical catheterisation (UC), administration of hypertonic dextrose or total parenteral nutrition via UC, exchange transfusion, blood culture proven sepsis, necrotising enterocolitis, antecedent abdominal surgery, birth asphyxia, omphalitis and underlying immunodeficiency. We present three cases of early infantile liver abscesses without any identifiable predisposing factor despite extensive work-up to search for such. Early recognition and management led to a favourable outcome in all our patients.

Protocol-based management of 154 cases of pediatric liver abscess

AIM

Although liver abscess (LA) is prevalent worldwide, especially in developing countries, there is a paucity of data regarding the protocol for management of LA in children. The aim of this study was to analyze the outcome of a protocol-based management of pediatric LA from a single institution.

MATERIALS AND METHODS

This prospective observational study was conducted in a tertiary-care children's hospital and included all patients with LA managed over a 5-year period. Detailed clinical, laboratory, microbiological and imaging parameters were recorded, and the patients were treated according to a standardized management protocol. Small abscesses (<5 cm) and those with solid appearance on initial ultra-sonogram (US) were managed with antimicrobial therapy alone. Liquefied abscesses on imaging were additionally subjected to US guided percutaneous needle aspirations (PNA). Large abscesses pointing to the surface were treated by percutaneous drainage (PCD). Ruptured LA, abscess inaccessible to image-guided drainage and those not responding to other modes of treatment were subjected to open surgical drainage (OSD). Pleural collections were treated by aspirations or intercostal tube drainage. Outcome was analyzed in terms of duration of recovery and complications including mortality.

RESULTS

Over the 5-year period, 154 pediatric LA patients underwent protocol-based management. The mean age of the patients was 6.76 years with the male:female being 1.26:1. Medical management alone, PNA, PCD and OSD were successful in 38 (24.6%), 76 (49.3%), 11 (7.14%) and 29 (18.8%) cases, respectively. Pleural collections developed in 43 (27.9%) patients out of which aspiration/drainage was needed in 24 (55.81%) cases. The mean duration of hospital stay was 20.67 ± 9.52 days. Ongoing sepsis and multi-organ failure lead to mortality in 6 (3.8%) cases; rest of the patients were doing well on follow-up.

CONCLUSION

Ultra-sonography was useful for the initial diagnosis, monitoring the progress and management of LA in children. The outcome of a protocol-based management of LA in children was favorable.

Ruptured Liver Abscess in Neonates: Report of Two Cases

Neonatal hepatic abscess is a rare disease seen mainly in preterm following umbilical catheterisation. Liver abscess in term neonates without any predisposing factor is still rarer and only few cases have been reported in the literature. Here we report two cases of liver abscess in term neonates presenting with abdominal mass due to rupture.

Pediatric Interventional Radiology: Non-Vascular Interventions

Pediatric interventional radiology (PIR), which includes variety of procedures done under image guidance has emerged as an essential adjunct to various surgical and medical conditions, plays a significant role in the delivery of safe and effective care by reducing surgical risks, decreasing the length of hospital stay and reducing costs. The application of interventional techniques in children has been delayed over years as compared to adults due to lack of special hardwares/equipments, lack of adequately trained physicians and also the lack of awareness among the pediatric practitioners. This situation is gradually changing now owing to the advancements in technology. In this review, authors will discuss various non-vascular interventional procedures undertaken in pediatric patients.

Neonatal liver abscesses due to Candida infection in a preterm infant, secondary to malpositioned umbilical lines--a rare entity

Neonatal liver abscess is an uncommon seen condition in neonatology and it holds a very high neonatal mortality because of difficulty in diagnosis and treatment. Till today, only few instances are reported that too are mainly in preterm. Its diagnosis requires a high index of suspicion. Fungal hepatic abscess is very rare and in medical literature very few case reports are there in the medical literature. Here, we report a case of Candida albicans liver abscess in a preterm neonate, secondary to malpositioned umbilical lines that presented with respiratory difficulty and other clinical features of sepsis that was managed medically and discharged successfully.

Usefulness of contrast-enhanced ultrasound with Sonazoid for evaluating liver abscess in comparison with conventional B-mode ultrasound

AIM

The purpose of this study was to evaluate the usefulness of contrast-enhanced ultrasound (CEUS) with Sonazoid (perfluorobutane) in patients with liver abscess. Sonazoid is a contrast agent with a low mechanical index and is phagocytosed by Kupffer cells.

METHODS

Twenty-two patients with liver abscess were evaluated with conventional US, real-time CEUS with Sonazoid, and enhanced computed tomography (CT). After 0.5 mL of Sonazoid was administrated i.v., CEUS images in the vascular and post-vascular phases were observed.

RESULTS

Conventional US showed hypoechoic lesions in 13 (59.1%), isoechoic in four (18.2%), hyperechoic in two (9.1%), mixed echoic in two (9.1%) and undetected in one (4.8%) patient. CEUS showed perilesional enhancement in 19 (86.4%) lesions in the vascular phase and well-defined unenhanced areas in 22 (100%) lesions in the post-vascular phase. CEUS revealed that 18 abscesses were cystic type and three were honeycomb type. Twenty-one abscesses (95.5%) had clearer appearances on CEUS than on conventional US in regard to the extent of necrotic or liquefied lesions seen. We could confirm reduction of the lesions after therapy in 13 (92.9%) of 14 patients followed up by CEUS.

CONCLUSION

Most of the liver abscesses showed perilesional enhancement in the vascular phase and unenhanced areas in the post-vascular phase. The appearance of liver abscesses was clearer on CEUS than on conventional US. CEUS with Sonazoid can be a more effective diagnostic and therapeutic tool for liver abscess.

Percutaneous drainage of abdominal and pelvic abscesses in children

It has only been in the last several decades that abscesses within deep compartments, particularly within the abdomen and pelvis, have become safely accessible with imaging guidance. Since that time, percutaneous abscess drainage has become the standard of care in children. We review the clinical features, diagnosis, and image-guided management of abdominal and pelvic abscesses in children.

Neonatal liver abscesses associated with candidemia: three cases and review of literature

BACKGROUND

Our aim was to identify risk factors for the development of neonatal Candida liver abscess and to find useful information to better manage this potentially fatal complication.

METHODS

A computerized search was conducted using PubMed. Overall, three articles describing the history of seven infants were finally considered. The characteristics of these seven cases were analyzed together with those of three new cases that we treated in the recent past.

RESULTS

All the neonates were premature. Previous antibiotic use was reported in all the cases, umbilical venous catheterization in 9/10 and total parenteral nutrition in 8/10. Candida albicans was isolated in 9/10. All the patients presented with aspecific signs of sepsis. Liver abscesses were described as "microabscesses" or "miliary abscesses" in three cases, as solitary lesion in two cases. In one case two lesions and in one four lesions were reported. Three infants died.

CONCLUSIONS

Liver ultrasonography should be performed in all the neonates with signs of sepsis, especially in the presence of candidemia and/or hepatomegaly and/or significant change in liver enzymes. Umbilical venous catheter should be removed, and peripheral IV access should be used until there is documented clearance from the blood with three or more negative blood cultures.

Liver fluid collection in neonates and its association with the use of a specific umbilical vein catheter: Report of five cases

In newborns, the presence of liver fluid collection is a rare event. The reported cases are isolated or described over long periods. Within four months, five neonates were diagnosed with liver fluid collection from safety occurrence reports. Clinical, laboratory and radiological data were extracted from medical records. The definite diagnosis was made by ultrasound. Four of the patients were preterm, male and had very low birth weights. The osmolality of the infused solution was within the acceptable range. Investigations revealed that the use of a new brand of umbilical vein catheter introduced in the neonatal intensive care unit, one month before the first case, was associated with this cluster. Low positioning of the umbilical vein catheter tip appeared to be a second contributory factor. Neonatal practitioners may benefit from the present report when facing the occurrence of similar lesions.

Pharmacological resolution of a multiloculated Candida spp. liver abscess in a preterm neonate

We report the case of a 31-week gestational age neonate with Candida albicans sepsis and a hepatic abscess. Diagnosis relied on clinical and radiological signs of sepsis, liver function impairment and culture isolation of Candida spp. from sterile sites. Liver ultrasound documented the presence of a multiloculated abscess. Treatment with micafungin (3 mg/kg/day) resulted in normalization of liver function and inflammatory laboratory values and improvement of clinical condition. After 30 days of treatment, the liver abscess resolved and at the 8-month follow up the infant is doing well. Prompt diagnosis and antifungal treatment avoided surgical drainage and liver surgery in this high-risk neonate.

[Neonatal liver abscess after umbilical venous catheter]

INTRODUCTION

The use of an umbilical venous catheter (UVC) is common practice in neonatal units and is subjected to strict rules of insertion and monitoring to detect potential complications. Hepatic abscess is one of these rare complications.

OBSERVATION

We report the observation of a 15-day-old female newborn admitted for a hepatic abscess. The patient had been hospitalized at birth in a neonatal intensive care unit. With the appearance of hemodynamic instability on the 4th day of life, a nosocomial infection was suspected and was treated with ceftazidime, vancomycin and amikacin. Later, as the need for O(2) increased and plasma C-reactive protein (CRP) was 190 mg/L, the patient received imipenem and vancomycin, while an abdominal ultrasound examination showed a hepatic abscess. A triple antibiotic treatment was initiated with imipenem, vancomycin, and metronidazole, while the initial examination showed a clinically stable patient with a CRP at 208 mg/L. Abdominal ultrasounds showed a hepatic abscess measuring 53.4×24.9 mm on day 21 and 51.4 mg/L CRP. Then the abscess dimensions decreased to 35.7×14 mm. The antibiotic therapy was maintained for 4 weeks.

CONCLUSION

Hepatic abscess should be suspected in neonates with UVC with sepsis and persistent signs of inflammation in spite of adequate antibiotic treatment.

Hepatic abscesses

Hepatic abscesses are potentially lethal diseases if early diagnosis and treatment are not instituted. They are prevalent all over the globe and pyogenic abscesses are predominant over amoebic. With better control of intra abdominal and systemic infections by a spectrum of antibiotics, aetiology of pyogenic abscesses are secondary to interventions and diseases in the biliary tree to a large extent today. The common organisms isolated are the Gram negative group. Amoebic abscesses continue to plague some regions of the world where hygiene and sanitation are questionable. Over the years, diagnosis, treatment and prognosis have evolved remarkably. Imaging modalities like ultrasonography and CT scan have become the cornerstone of diagnosis. The absence of ionizing radiation makes MRI an attractive alternative in patients who require multiple follow up scans. Serological testing in amoebic abscesses has become more reliable. Though antibiotics have remained the principal modality of management, percutaneous drainage of abscesses have vastly improved the chances of cure and bring down the morbidity drastically in pyogenic abscesses. Amoebic abscesses respond well to medical treatment with nitroimidazoles, and minimally invasive surgical drainage is an option in cases where open surgery is indicated.

Identification of high-risk group and therapeutic options in children with liver abscess

The outcome of children with liver abscess (LA) depends upon prompt diagnosis and intervention. We evaluated the etiology, clinical profile, various interventional modalities of management and outcome of children with LA. A total of 39 hospitalized children (mean age 7.2 ± 3.9 years) with radiologically proven LA were analyzed. Parenteral antibiotics, percutaneous drainage (PD) or open surgical drainage (OSD) was done as required. Cases with ruptured or impending rupture of LA, upper gastrointestinal bleed, jaundice, pleural effusion or consolidation were labeled as "high risk" cases. Triad of fever, pain and hepatomegaly was the most common presentation. Single abscess was present in 66.7% and right lobe was involved in 69.2% of cases. Majority of LA were pyogenic (PLA, 25/39). Amebic liver abscess (ALA) and PLA had similar clinical and laboratory profile except that multiloculated abscess on ultrasonography was a feature of PLA (12/25 vs. 0/11; p = 0.006). Cases with ALA settled significantly more often with antibiotics alone (5/11 vs. 3/25; p = 0.04) than PLA and none required surgery (0/11 vs. 7/25; p = 0.03). Subjects with "high-risk" LA (n - 26) had significantly larger abscesses, more polymorphonuclear leucocytosis (74 ± 15% vs. 61 ± 13%; p = 0.01) in peripheral blood and need of drainage (24/26 vs. 7/13; p = 0.03) than patients with average-risk LA. Based on the results, 38/39 children recovered, with complete abscess resolution in 28, over 48 ± 63.8 days. In conclusion, ALA, although similar in presentation, are uniloculated, and patients with ALA recover more often without drainage than patients with PLA. Patients with "high risk" LA are more common and have a good outcome with drainage. PD, being safe, efficacious and less invasive than OSD, should be the preferred drainage procedure.

Gastrointestinal intervention in children

Interventional radiology is a rapidly growing discipline in paediatrics. Many non-vascular interventional techniques may be used in the gastrointestinal tract in children. The technically simpler and more common of these may be adopted by any paediatric radiologist with an interest in interventional radiology. Other rarer and more complex techniques are currently restricted to specialist centres with a higher overall caseload. This review emphasizes the common procedures such as oesophageal dilatation, gastrostomy, insertion of transgastric jejunal feeding tubes and biopsy. Less common salivary, hepatobiliary, pancreatic and intestinal interventions are also described.

Pyogenic liver abscess: Changing patterns in approach

AIM

To define optimum management of the pyogenic liver abscess and assess new trends in treatment.

METHODS

One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment.

RESULTS

Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.

CONCLUSION

Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.

Liver abscess in neonates

INTRODUCTION

Liver abscesses are rare in neonates with the majority resulting from an ascending infection via the umbilical and portal veins, haematogenous spread, or via the biliary tree, or via direct contiguous spread from neighbouring structures. They may present in unusual ways often presenting with ongoing sepsis and resulting in diagnostic difficulties. We present the clinical and radiological findings on six neonates with hepatic abscesses and underline the association with misplacement of umbilical line, association with hypertonic glucose infusions and TPN.

METHODS

A retrospective chart review made of six patients diagnosed with hepatic abscesses between 2000 and 2006. Methods included clinical and radiological review as well as evaluation of potential risk factors.

RESULTS

Five of the six patients with neonatal liver abscess were of low birth weight and low gestational age (range 30-34 weeks), but one was post mature (42 weeks). Sex distribution was equal and two were HIV exposed (mother positive), two HIV negative with two having an unknown HIV status. Clinical signs included raised infective markers (CRP) (6) and non-specific signs of septicaemia (4), but a tender hepatomegaly (1) and abdominal distension with ileus (1) were also noted. Five were right-sided abscesses (2 associated with malposition of umbilical line) and one central in position. Predisposing factors included association with a misplaced umbilical line with high concentration glucose infusions (2) and tuberculosis was later diagnosed in one. Infective markers (CRP) remained high with positive blood cultures persisting in all. Causative organisms included Klebsiella (3) Staphylococcus (3) [one a multi-resistant staphylococcus (MRSA)], Gonococcus (1) and Enterobacter (1). Abdominal X-ray demonstrated a mal-positioned umbilical line in three patients (50%). Ultrasound (US) proved a reliable method of diagnosis although some difficulty was encountered in interpreting resolving abscesses and trans-diaphragmatic spread occurred in one. Three patients (50%) responded to antibiotic therapy alone, but interventional drainage was required in the remainder. Needle aspiration was successful in two of these, but one further patient had a radiologically placed pigtail drainage, but later required open drainage. This patient then developed trans-diaphragmatic spread and empyema requiring thoracoscopic decortication.

CONCLUSION

Neonatal hepatic abscesses are rare but should enter the differential diagnosis of a neonate with ongoing sepsis. This study serves to draw attention to their association with misplaced central (umbilical) catheters. Failure to respond to antibiotic therapy necessitates interventional drainage.