[Aspergillus peritonitis--a case report]

The incidence of fungal infections such as Aspergillosis is increasing among immunocompromised patients. Demand for diagnosis of mycotic diseases is steadily raising among clinicians and treatment of these patients represents a continually growing challenge. The authors present a case of a 53-year-old male patient with Aspergillus peritonitis. This case deserves attention because its extreme rarity in the medical literature and complex therapy of coinfections during the hospital stay which was difficult and relatively expensive. The importance of consultation and microbiological sampling is emphasized.

Subhepatic appendicitis with subdiaphragmatic abscess in a pediatric patient without intestinal malrotation: case report

BACKGROUND

Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. When these conditions are met, accurate diagnosis and early management decisions are delayed.

CLINICAL CASE

We present the case of a 10-year-old male who had diarrhea without mucus or blood for 5 days. He was treated with antibiotics. Afterwards, he presented with vomiting, abdominal pain, and fever. Physical examination of the abdomen demonstrated a soft and depressible mass and pain in the lower right abdomen. Abdominal ultrasound and tomography reported image of subdiaphragmatic abscess. Percutaneous puncture and drainage were performed without results. Exploratory laparotomy was then performed, revealing a subhepatic perforation of the appendix. The patient evolved with abdominal sepsis and septic shock, resulting in a new surgical intervention for drainage of serohematic fluid. The patient improved and was discharged on day 40.

DISCUSSION

It is very important to consider the position of the anatomic appendix during appendicitis because it contributes to the various clinical symptoms, of which 30% are atypical. Diagnosis is masked, leading to complications such as perforations and/or abscesses that extend the hospital stay.

CONCLUSIONS

Acute subhepatic appendicitis in children is an uncommon presentation. It is usually associated with intestinal malrotation. Delay in treatment due to atypical symptoms caused by the abnormal position of the appendix conditioned complications that implied a prolonged hospital stay, with the risk of increasing morbidity and mortality of the patient.

Transphrenic fistulization of a subphrenic abscess to lung parenchyma

A 53-year-old woman was admitted with respiratory distress. For several years, she had chronic alcoholic pancreatitis with ductal stones that were treated with a stent and with shockwave lithotripsy. Both treatments were unsuccessful, and the pancreatitis was complicated with an infected pseudocyst. The pancreatic head had to be resected, which was complicated with recurrent subphrenic abscesses. She then was admitted with respiratory distress and initially diagnosed with pneumonia of the right lower lobe. Further investigations showed supradiaphragmatic and subdiaphragmatic air-fluid levels. In both collections Streptococcus milleri was cultured, and subsequently the patient was diagnosed with a fistula connecting the subdiaphragmatic abscess with pulmonary tissue. This was treated with intravenous amoxicillin/clavulanate and drainage of the subdiaphragmatic collection. She did not develop a pulmonary empyema, because multiple adhesions, which were due to recurrent abscesses after pancreatic surgery, prevented breakthrough into the pleural cavity.

Cholelithoptysis: an unusual delayed complication of laparoscopic cholecystectomy

We report the case of a 54-year old woman who presented with a persistent right lower lobe pneumonia followed by cholelithoptysis, 11 months after a laparoscopic cholecystectomy. It is postulated that this was a result of the formation of a subphrenic abscess secondary to intraoperative spillage of gallstones. It is concluded that spillage of gallstones at laparoscopic cholecystectomy is not as benign as previously thought and that efforts to prevent spillage should include scrupulous operative technique, especially in the presence of gallbladder inflammation, and especial care when removing the gallbladder from the abdominal cavity.

[Subphrenic abscess during the course of acute brucellosis: diagnosis and treatment with percutaneous sonographically-guided drainage]

Abscess formation during the course of acute brucellosis is a rare event. A case of subphrenic abscess, the first to our knowledge, is described. A 49 years-old male patient with fever and a mild increase in ALT and gamma-GT was referred to our Institution. Routine blood exams tested negative and antibodies against Brucella spp. Were also negative. CT examination of abdomen was normal. After 8 days, US examination showed a liquid area under the right diaphragma and US-guided puncture revealed an abscess; pus culture showed the presence of Brucella melitensis. Seven days later theWright reaction became positive. After percutaneous catheter drainage of the abscess, fever disappeared and US follow-up showed reconstitution of subphrenic space. Our study confirm that sonography is a valid method to demonstrate abdominal abscess and that US-guided percutaneous puncture and drainage are useful tools in diagnosis and treatment of fluid abdominal collections

An unusual paratyphoid fever

Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.

Extraction of retained gallstones from an abscess cavity: a percutaneous endoscopic technique

A novel technique to retrieve spilled gallstones in an abscess cavity with the use of minimally invasive techniques is described.

CT findings in post-operative subphrenic abscess with teratomatous inclusions

A 39-year-old woman presented with abdominal pain after tubal sterilization. CT showed a subphrenic abscess with fatty inclusions owing to laceration or rupture of a mature ovarian teratoma. Although subphrenic abscess is a well recognized post-operative complication, and ovarian teratomas are frequent, a teratomatous inclusion within a subphrenic abscess is a unique finding.

Bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess

We treated a case of bronchoperitoneal fistula secondary to a Klebsiella pneumoniae subphrenic abscess. This fistulous communication and the surgical procedure used to treat it are described.

Centrocytic lymphoma presenting as a subphrenic abscess and a solitary liver nodule

Non Hodgkin's lymphoma revealed by hepatic manifestations is extremely rare. We describe here a 82-year old male patient who presented with a right subphrenic abscess and a solitary liver tumour that was shown to be a centrocytic lymphoma. Furthermore, asymptomatic cryptogenic liver cirrhosis was diagnosed. This previously unreported form of clinical presentation of a non Hodgkin's lymphoma as well as the association with liver cirrhosis are discussed in the context of the recent literature.

[Use of collagen and gentamycin in the treatment of chronic soft tissue lesions]

The authors describe two case-histories where Garamycin-schwamm was used in the treatment of a chronic fistula and cavities in the subphrenium resulting from treatment of a subphrenic abscess, and in the pelvis minor as a result of a fistula which developed after establishment of an ileoanal intestinal pouch. They confirm the experience of authors abroad with the treatment of chronic cavities in soft tissues as a result of operations, which so far had to be treated by other methods.

Pleuritic pain and fever

Images

Transphrenic dissemination of actinomycosis

Thoracic actinomycosis is an uncommon disease and often presents difficulty in diagnosis. Two cases are presented in which thoracic actinomycosis produced fistulae between the thoracic and abdominal cavities. Surgical drainage and high dose penicillin for at least 4-6 months was the treatment of choice.

Rupture of splenic artery pseudoaneurysm

Pseudoaneurysms of the splenic artery have been well described in association with pancreatic pseudocysts secondary to pancreatitis. We present a case of a ruptured splenic artery pseudoaneurysm 14 years after splenectomy for trauma which, at that time, was complicated by a subphrenic abscess.

Endoscopic (-ERC) fibrin sealing and histoacryl sealing of an abscess induced bilio-hepatico-cutaneous and a bilio-hepatico-phrenico-bronchial fistulous system

We report the case of a female patient with persisting bilio-bronchial and bilio-cutaneous fistulae originating in the right liver lobe. The causative factor was a subphrenic liver abscess which had been adequately and successfully treated. No biliary obstruction was detectable on admission. Because of her previous medical history the patient was considered to be a high surgical risk. Therefore the described endoscopic (ERC) approach was chosen. Here we describe the first successful attempt to close such a fistulous system by repeated fibrin and histoacryl-sealing through an endoscopically guided catheter. The success of this innovative procedure may be helpful, in the management of similar cases in the future.

Left pleural effusion: masking subphrenic abscess--caused by Salmonella enteritidis serotype Heidelberg

The authors describe a young girl presenting with fever and respiratory distress and a chest x-ray showing a left lower lobe infiltrate and an effusion. She also had splenomegaly. Salmonella enteritidis serotype Heidelberg was isolated by thoracentesis. Further evaluation disclosed an occult but large left subphrenic abscess, explaining the misleading presentation and radiograph. A review of salmonella infections associated with subphrenic abscess is discussed.

[Transdiaphragmatic bronchopleural fistulas as complications of subdiaphragmatic abscesses]

The authors had 21 patients with various types of transdiaphragmatic bronchopleural fistulas which development as secondary complications of a subdiaphragmatic abscess as a consequence of late diagnosis, ineffective drainage, and use of transpleural approaches to the abscesses. Clinical and radiological diagnosis including contrast fistulo- and pleurography, bronchography and bronchoscopy, and contrast endoscopic examination of the stomach and other organs made it possible to determine the character and localization of the transdiaphragmatic fistula and the condition of the sprained organs. The therapeutic tactics were determined by the form and causes of the transdiaphragmatic bronchopleural fistulas. Nineteen patients recovered, 2 died. The success of treatment depended on the time when operative drainage was begun and on its rational application on bronchological cleansing, and on other components of complex treatment.

Splenobronchial fistula: interventional radiologic management

A 71-year-old man had a splenic abscess complicated by rupture into the left subphrenic space with formation of a splenobronchial fistula. One percutaneous catheter was placed into the splenic abscess and a second was placed in the subphrenic collection. The abscesses resolved and the bronchial fistula closed in 12 days.

Subphrenic abscess: a pulmonary presentation

A patient with subphrenic abscess can present with pulmonary or abdominal symptoms because of the location of the abscess adjacent to the diaphragm. This thoracoabdominal clinical complex has been described previously and, if chest symptoms predominate, may obscure the diagnosis of subphrenic abscess. The case of a patient with occult abdominal pathology who presented with respiratory complaints is discussed.

[Extended, combined and associated resection of the liver]

The authors describe their observations of 227 patients after operations for focal lesions of the liver. Radical operations were performed on 93 patients, 61 being subjected to extended, combined and associated resections of the liver. Most operations were made as atypical resections of the liver. In order to reduce the operation blood loss the authors recommend to fulfil temporary exclusion of the liver from blood circulation by compression of the hepato-duodenal ligament. The temporary external drainage of bile ducts is recommended as a preventive measure against post-operative bile peritonitis. Postoperative lethality after extended, combined and associated resections of the liver was 9.8%.

Difficulty in diagnosing complications of Caroli's disease

Congenital cystic dilatation of the biliary tree (Caroli's disease) is a rare condition that usually presents with ascending cholangitis. This report demonstrates the difficulty of recognizing other complications of Caroli's disease antemortem. A 35-year-old man developed a subphrenic abscess and malignant transformation of the biliary tree; both were clinically undetected. Episodes of pain, pyrexia, or weight loss should be assessed carefully and the complications of Caroli's disease considered before attributing such symptoms to recurrent cholangitis.

Pseudo-splenomegaly as a result of subphrenic abscess

A case of left-sided subphrenic abscess, secondary to perforation of a carcinoma of stomach, is described. The patient presented with a palpable spleen which was shown to be normal in size but displaced by the subphrenic collection. The importance of correct interpretation of this physical sign is discussed.

Exudative pleural effusions secondary to gastrointestinal diseases

Several different diseases of the gastrointestinal tract may have an associated exudative pleural effusion. In the acutely ill patient with a pleural effusion, the possibility of esophageal perforation should always be considered. It is important to establish this diagnosis as soon as possible since the mortality rate increases markedly if drainage of the mediastinum is delayed for even 12 or 24 hours. The best screening test for esophageal rupture is the level of amylase in the pleural fluid. All patients with undiagnosed exudative pleural effusions should have the amylase level in their pleural fluid measured to rule out a pancreatic etiology for their pleural effusion. In patients with acute pancreatitis, the clinical presentation may be dominated by chest symptoms. Such patients have small to moderately sized pleural effusions that resolve rapidly once appropriate therapy is instituted. If symptoms persist, the possibility of a pancreatic abscess or a pancreatic pseudocyst should be considered. Patients with pancreatic pseudocysts may develop a sinus tract between the pseudocyst and the pleural space. In this situation a large pleural effusion develops. Frequently there are no abdominal symptoms and the diagnosis will not be made unless a pleural fluid amylase is obtained. Patients with exudative pleural effusions that contain predominantly polymorphonuclear leukocytes should be suspected of having an intra-abdominal abscess, particularly when there is no associated parenchymal infiltrate. Subphrenic, intrahepatic, and splenic abscesses all have a high incidence of accompanying pleural effusion. Abdominal CT scanning is the method of choice to establish each of these diagnoses.

Hepatobiliary-lung imaging. A case report

The use of combined hepatobiliary-lung imaging in the diagnosis and evaluation of a subphrenic process is described.

Empyema following intra-abdominal sepsis

Over the past 9 years, ten patients have presented to the Thoracic Unit, Glasgow Royal Infirmary, with 12 empyemas secondary to intra-abdominal sepsis. In eight patients, the presenting signs and symptoms were wrongly attributed to primary intra-thoracic pathology. All were subsequently found to have intra-abdominal sepsis. The presence of empyema after recent abdominal surgery or abdominal pain strongly suggests a diagnosis of ipsilateral subphrenic abscess. Adequate surgical drainage is essential. In our experience, limited thoracotomy with subdiaphragmatic extension offers the best access to both pleural and subphrenic spaces and provides the greatest chance of eradicating infection on both sides of the diaphragm.

An unusual presentation of carcinoma of the colon in a child. A case report

A patient with carcinoma of the large bowel who presented with a subphrenic abscess is reported. This case emphasizes two important facts relating to colonic cancer in childhood: (i) premalignant disease of the large bowel is no prerequisite for the development of colonic cancer; and (ii) in childhood this disease is characterized by a fulminating course and high mortality. In about 50% of cases the tumour is of the signet ring or mucin-producing type, which explains the grave prognosis.

Percutaneous drainage of abdominal fluid collections in children

Percutaneous drainage of intraabdominal fluid collections was performed in 13 children. After initial diagnosis with either sonography or computed tomography, a smallbore aspiration needle (22 gauge) was guided into the collection, usually by sonography. In five patients, complete evacuation was possible using the aspirating needle alone. In seven others, the fluid was successfully drained via a catheter introduced percutaneously. In one patient, surgery was required for complete evacuation of a hematoma containing large blood clots. There were no complications.

Continuing changing patterns of disease in pyogenic liver abscess: a study of 38 patients

Changes in the etiology, clinical features, methods of diagnosis, and treatment of pyogenic liver abscess have occurred slowly but continuously over the past century. The earlier changes are well documented in the literature, and continuing variations in the classic patterns of disease are now evident. These include 1) a recent increase in incidence reflecting more accurate diagnostic techniques; 2) changes in bacteriology with a high incidence of Klebsiella infection; 3) a reduction in mortality, reflecting earlier diagnosis and more refined therapeutic methods; and 4) changes in the population at risk namely a large population of terminal cancer patients. Thirty-eight patients treated at the Mount Sinai Hospital over the past 16 years, 1967-1982, have been divided into two groups, each of 8 years duration, reflecting an earlier era before routine use of scanning procedures, and a later period when technetium, gallium, sonographic, and more recently CT imaging procedures were regularly done. During the latter period there was a significant increase in both the total number of liver abscesses diagnosed and in the number estimated as a proportion of all hospital admissions. Mortality has continued to fall to more acceptable levels with a 25% reduction overall. In the early era, extrahepatic intra-abdominal infection caused all four deaths. In the past 8 years obstructing or metastatic cancer has caused four of the five deaths. Bacteremia occurred in six of the nine deaths, five of these being of biliary origin. The decrease in mortality may reflect earlier diagnosis, an increase in the number of solitary abscesses, and better therapy.