Clinical characteristics and management of liver abscess in The Gambia, a resource-limited country.

Liver abscess is endemic in resource-limited countries such as The Gambia where access to advanced imaging techniques or modern treatment modalities is limited. Despite this, mortality in this cohort was low. Therefore antibiotic therapy combined with percutaneous abscess drainage remains a reasonable treatment strategy of liver abscess in resource-poor settings.

Liver abscess in the caudate lobe caused by Klebsiella pneumoniae: a rare case report and literature review.

BACKGROUND: K. pneumoniae liver abscess (KPLA) mostly involves the right lobe. We present a case of K. pneumoniae caudate liver abscess with invasive liver abscess syndrome (ILAS) was rarely identified. CASE PRESENTATION: A 53-year-old man with elevated glycated hemoglobin with chills, rigors and a fever of five days. The patient presented with tachycardia and fever. Physical examination revealed tenderness over the right abdomen was elicited. In particular, the inflammatory markers were markedly elevated, and computerized tomography (CT) showed pulmonary abscess, pulmonary embolism and caudate liver abscess. The patient's sequential organ failure assessment (SOFA) score was 10 points. Klebsiella pneumoniae was isolated from sputum, urine and blood. With the suspicion of liver abscesses, ILAS and sepsis. The patient was successfully treated with antibiotics. He returned to close to his premorbid function. CONCLUSION: K. pneumoniae caudate liver abscess was rare. This is the first detailed report of K. pneumoniae caudate liver abscess with invasive liver abscess syndrome. Patients with cryptogenic K. pneumoniae liver abscess are advised to undergo an examination of intestinal barrier function. The study indicates that in patients with K. pneumoniae liver abscess, a caudate liver abscess size of ≤ 9.86 cm² may be characteristic of those suitable for conservative treatment of invasive liver abscess syndrome.

Double trouble: an unusual case of Klebsiella pneumoniae invasive syndrome with liver abscess, gallbladder empyema and infective endocarditis.

BACKGROUND: Klebsiella pneumoniae invasive syndrome (KPIS) is characterized by primary pyogenic liver abscess associated with metastatic infections. Although rare, Klebsiella endocarditis carries a high mortality risk. CASE PRESENTATION: A 60-year-old lady with type II diabetes mellitus presented with fever, malaise, right hypochondriac pain and vomiting for two weeks. Ultrasound abdomen revealed a collection within liver, and distended gallbladder with echogenic debris within. 3 days after ultrasound guided pigtail drainage of gallbladder empyema, newly presence murmur detected. Pus, urine, and blood cultures obtained were positive for Klebsiella pneumonia. Echocardiogram exhibited oscillating mass attached to anterior mitral valve leaflet. After 6 weeks of intravenous ceftriaxone, follow-up echocardiogram and ultrasound showed complete resolution of mitral valve vegetation, hepatic and gallbladder collection. CONCLUSION: Concomitant extrahepatic infective endocarditis (IE) should raise concerns in daily practice for patients with Klebsiella pneumoniae liver abscesses, despite the rarity of Klebsiella endocarditis. In the absence of diagnostic suspicion, antibiotic treatment regimens may be shortened, and adverse effects from IE infection may ensue.

Surgical Treatment of an Abdominal Aortic Aneurysm in a Patient with a Liver Abscess.

The presence of an intraperitoneal source of infection, e.g., a liver abscess, can be an obstacle to performing an abdominal aortic surgery with a midline laparotomy because graft infection is one of the most critical complications of aortic surgery. We report the successful Y-grafting of a pararenal abdominal aortic aneurysm through a retroperitoneal approach in a 67-year-old male undergoing liver abscess drainage. The retroperitoneal approach to the abdominal aorta may be useful for abdominal aortic surgery in patients with a localized intraperitoneal infection.

[A case of abscessed hepatic hemangioma with Edwardsiella tarda].

A 55-year-old man with a history of pancreatic cancer surgery and was undergoing chemotherapy presented with high fever. A computed tomography scan revealed a liver abscess at the location of a previously identified hemangioma. PTAD was performed, and contrast imaging revealed a connection with the bile duct. Edwardsiella tarda was detected in the abscess culture. Hemangioma-related abscess formation is extremely rare, with no reported cases of E. tarda detection in such abscesses.

[A case of liver abscess with meningitis and endophthalmitis: invasive liver abscess syndrome].

A woman in her 70s was hospitalized and was diagnosed with liver abscess and managed with antibiotics in a previous hospital. However, she experienced altered consciousness and neck stiffness during treatment. She was then referred to our hospital. On investigation, we found that she had meningitis and right endophthalmitis concurrent with a liver abscess. Klebsiella pneumoniae was detected from both cultures of the liver abscess and effusion from the cornea. A string test showed a positive result. Therefore, she was diagnosed with invasive liver abscess syndrome. Although she recovered from the liver abscess and meningitis through empiric antibiotic treatment, her right eye required ophthalmectomy. In cases where a liver abscess presents with extrahepatic complications, such as meningitis and endophthalmitis, the possibility of invasive liver abscess syndrome should be considered, which is caused by a hypervirulent K. pneumoniae.

Ultrasound-guided aspiration in addition to antibiotics for treatment of liver abscess in children: A randomized controlled trial.

BACKGROUND AND AIM: The criteria for aspiration for pediatric liver abscess are unclear. In this randomized controlled trial, we evaluated the efficacy of ultrasound-guided needle aspiration in addition to antibiotics in children with uncomplicated liver abscess. METHODS: We enrolled 110 children aged 1-18 years (mean [SD] = 7.7 [3.7] years) with uncomplicated liver abscess. The primary outcome was clinical cure at 6 weeks (absence of fever and abdominal pain in the preceding 14 days with reduction in abscess size on ultrasonography). The secondary outcomes were clinical response at 4 weeks, fever resolution time, time to abdominal pain reduction and abdominal tenderness, duration of hospitalization, and treatment failure. RESULTS: Clinical cure at 6 weeks was not significantly different (48/50 [96%] vs 39/46 [85%]; P = 0.082) between aspiration plus antibiotics group and antibiotics only group. The clinical response at 4 weeks was also comparable (49/50 [98%] vs 43/46 [93.5%]; P = 0.347). The mean (SD) of fever resolution time was significantly less in the aspiration plus antibiotics group (198 [90.8] h vs 248.2 [104.6] h; P = 0.014). Time to achieve reduction in abdominal pain (8.32 [3.1] vs 9.46 [3.1] days; P = 0.077) and abdominal tenderness (5.7 [2.4] vs 6.3 [2.3] days; P = 0.242), duration of hospitalization (16.6 [3.9] vs 18.2 [4.4] days; P = 0.07), and adverse event profile (9/50 [18%] vs 14/46 [30%]; P = 0.217) were comparable between the two groups. CONCLUSION: Majority of children with uncomplicated liver abscess achieved clinical cure at 6 weeks with intravenous antibiotics, irrespective of aspiration. However, needle aspiration may slightly reduce the duration of fever and abdominal pain/abdominal tenderness.

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.

Liver abscess due to parvimonas micra.

Liver abscesses are an entity that sets out a diagnostic challenge with a severe clinical course and non-negligible mortality. Their origin is usually bacterial (>80%), parasitic, mixed or, more rarely, fungal. We present the case report of a 45-year-old man, native of Ghana, with no relevant medical-surgical history, was admitted for septic shock with multiple organ dysfuntion syndrome. Complementary imaging tests revealed a liver abscess in segments IV and VII measuring 60x45x54 mm, so antibiotic treatment with piperacillin-tazobactam was started and a pigtail drainage was placed. In blood cultures, the microorganism parvimonas micra (anaerobic gram-positive cocci) was isolated with high degree of sensitivity rates to penicillin, clindamycin and metronidazole. Treatment was de-escalated to clindamycin until completing 4 weeks of intravenous treatment. Control CT showed a decrease in the size of the abscess and pigtail drainage was removed.

Liver abscess as a atypical presentation of hepatocellular carcinoma.

We present the case of a 64-year-old male with a history of chronic liver disease due to hepatitis C virus, with a sustained viral response after oral antiviral treatment and without follow-up for 5 years. He was admitted after a one-month history of constitutional symptoms, low-grade fever, abdominal pain and a palpable epigastric tumor. Analysis showed marked elevation of acute phase reactants (48,000 leukocytes and C-reactive protein of 19mg/dl) and dissociated cholestasis. Two lesions were identified by abdominal CT.

Leverabscess utløst av et fiskeben.

BACKGROUND: Liver abscess caused by foreign bodies constitutes a rare medical problem that few of us will encounter in a clinical setting. CASE PRESENTATION: We describe a case where a woman presented with sepsis and abdominal pain. Computed tomography (CT) of her abdomen revealed a large hepatic abscess containing a foreign body. Based on the size, shape and density of the object, a fishbone was suspected. INTERPRETATION: We hypothesise that she swallowed a fishbone, which then perforated the gastrointestinal tract and lodged in the liver. After interdisciplinary discussion it was decided to proceed with conservative management, and the patient was treated successfully with antibiotics for a total of 31 days.

[A case of invasive liver abscess syndrome caused by Klebsiella pneumoniae causing endophthalmitis-induced blindness].

An 82-year-old female patient was admitted to our hospital for visual acuity loss in both eyes. The patient was diagnosed with invasive liver abscess syndrome and bilateral endophthalmitis due to Klebsiella pneumoniae 4 days after the onset of ocular symptoms. The liver abscess improved by broad-spectrum antibiotics and intravitreal injection, but bilateral blindness occurred. Most literature reported fever as the first symptom of invasive abscess syndrome, but this case had no fever at the onset of ocular symptoms. Delayed invasive liver abscess syndrome diagnosis might cause poor visual acuity prognosis.

[A case of irreversible metronidazole encephalopathy during liver abscess treatment].

Metronidazole (MNZ) is a widely used drug for protozoan and anaerobic infections. The continuous use of MNZ causes various neurological symptoms, such as cerebellar ataxia, visual disturbance, vestibulocochlear symptoms, gait disturbance, dysarthria, and epileptic seizures of unknown cause, named MNZ-induced encephalopathy (MIE), in rare cases. MIE is a reversible disease that often improves within a few days of MNZ discontinuation, but irreversible neurological symptoms rarely remain. Herein, we report a case of MIE that developed during MNZ administration for a liver abscess, causing prolonged unconsciousness and death even after drug discontinuation. An 85-year-old female patient complained of fever, elevated liver enzymes, and a multifocal abscess in the right hepatic lobe, as seen on computed tomography. Percutaneous transhepatic abscess drainage and antibiotic therapy were initiated. The causative agent of the liver abscess could not be identified, thus meropenem was started, which demonstrated no inflammation improvement, thus oral MNZ was added. The inflammation recurred when MNZ was discontinued, and the patient continued taking MNZ. Vomiting, upper limb tremors, consciousness disturbance, and convulsions appeared on day 46 (total dose of MNZ 73.5mg), and the patient was hospitalized. T2-weighted, diffusion-weighted, and FLAIR head magnetic resonance imaging (MRI) revealed symmetrical abnormal high-signal areas in the cerebellar dentate nucleus, corpus callosum, cerebral white matter, and periventricular areas. MIE was diagnosed based on the patient's course and MRI images, and MNZ was discontinued. The patient continued to suffer from impaired consciousness and convulsions after MNZ discontinuation and died due to aspiration pneumonia. Suggestively, MIE development is related to long-term MNZ administration, poor nutrition, liver disease, underlying diseases (such as advanced cancer), and serious complications. A systematic review of MIE cases revealed that 4.8-5.9% of the patients demonstrated little improvement of symptoms after MNZ discontinuation, and some deaths were reported. Patients with poor prognosis were often suffering from impaired consciousness and convulsions. Furthermore, impaired consciousness was the most common residual symptom. Abnormal signals in characteristic areas, such as the dentate nucleus cerebri and corpus callosum, on head MRI are useful for MIE diagnosis, especially in patients with abnormal findings in the cerebral white matter, which is associated with a poor prognosis. We should pay close attention to the onset of MIE when MNZ is administered.

Development and validation of a prediction model based on clinical and CT features for invasiveness of K. pneumoniae liver abscess.

OBJECTIVES: Klebsiella pneumoniae liver abscess (KPLA) complicated with extrahepatic migratory infection (EMI) is defined as invasive KPLA. The current study aimed to develop and validate a risk prediction model for the invasiveness of KPLA. METHODS: From 2010 to 2020, KPLA patients from four institutes were selected retrospectively. In the development cohort, risk factors from a logistic regression analysis were utilized to develop the prediction model. External validation was performed using an independent cohort. RESULTS: A total of 382 KPLA patients comprised two separate cohorts: development cohort (institute 1, n = 286) and validation cohort (institute 2-4, n = 86). The overall incidence of EMI was 19.1% (development cohort, n = 55; validation cohort, n = 18, p > 0.05). In the development cohort, four risk factors (age ≤ 40 years, fasting blood glucose (FBG) > 7 mmol/L, no rim enhancement, and thrombophlebitis on CT), significantly associated with EMI, were incorporated into the scoring system. The area under curve (AUC) of the receiver operating characteristic curve (ROC) in the development and validation cohorts was 0.931 (95% confidence interval [CI]: 0.93-0.95) and 0.831 (95% CI: 0.86-0.91), respectively. The calibration curves fitted well. The incidence of EMI was 3.3% and 56.5% for the low- (total scores ≤ 4) and high-risk (total scores > 4) groups in the development cohort, and 3.2% and 66.7% in the validation cohort (all p < 0.001), respectively. CONCLUSIONS: Age ≤ 40 years, FBG > 7 mmol/L, no rim enhancement, and thrombophlebitis were independent risk factors for EMI. This validated prediction model may aid clinicians in identifying KPLA patients at increased risk for invasiveness. KEY POINTS: • Four risk factors are significantly associated with extrahepatic migratory infections (EMI): age ≤ 40 years, fasting blood glucose (FBG) > 7 mmol/L, no rim enhancement, and thrombophlebitis on CT. • Based on these risk factors, the current study developed and validated a prediction model for the invasiveness of Klebsiella pneumoniae liver abscess (KPLA). • This validated prediction model may in the help early identification of KPLA patients at increased risk for invasiveness.

Cerebral venous sinus thrombosis in a patient with Klebsiella pneumoniae primary liver abscess: a case report.

BACKGROUND: Liver abscess is a common emergency in the emergency department. However, cerebral venous sinus thrombosis (CVST) is a rare and serious cerebrovascular disease. Cases of CVST in patients with Klebsiella pneumoniae primary liver abscess (KLA) have not been described in the literature. We report a case of CVST in patients with KLA. CASE PRESENTATION: A 54-year-old male patient came to our department with a fever for 2 days and altered mental status for 1 day. Abdominal computed tomography (CT) and liver magnetic resonance imaging (MRI) revealed multiple liver abscesses. The blood culture was identified as Klebsiella pneumoniae sepsis. Head contrast-enhanced MRI and magnetic resonance venography (MRV) imaging showed multiple thrombus formation in the right transverse sinus and sigmoid sinus. The patient's infection and thrombosis were controlled within one week of multidisciplinary comprehensive treatment such as antibiotic and antithrombotic therapy, and a good clinical recovery during the 1-month follow-up. CONCLUSION: CVST after liver abscess is rare, clinicians should be aware of this complication and vigilant for the possibility of bacterial meningitis. The underlying mechanisms need to be further studied.

Differentiation of Small Hepatic Abscess From Hepatic Metastasis With a Combination of Imaging Parameters.

OBJECTIVE: We aimed to evaluate the diagnostic performance of the combination imaging features to differentiate small (the lesion size of 3 cm or less) hepatic abscess from metastasis. METHODS: This retrospective study included patients with preexisting malignancy and small hepatic lesions who underwent contrast-enhanced computed tomography (CT) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) within 4 days between March 2017 and July 2020. Two radiologists independently evaluated the imaging features of each focal hepatic lesion. Laboratory parameters were also recorded. Significant parameters differentiating hepatic abscess from hepatic metastasis were identified by univariate generalized estimating equation regression. We compared the diagnostic performances of laboratory parameters, imaging features, and their combinations. RESULTS: We included 16 patients (10 males and 6 females) with 35 hepatic abscesses and 21 patients (13 males and 8 females) with 62 metastases with a mean age of 70.3 years in this study. Abnormal segmental neutrophil, pathy parenchymal enhancement on CT, and absence of dark rim on MRI were associated with hepatic abscess (all P < 0.01). The combination of CT and MRI parameters showed significantly higher specificity and positive predictive value than CT alone ( P ≤ 0.031), without significant difference in sensitivity and negative predictive value. CONCLUSIONS: We have demonstrated that the combination of CT and MRI imaging features is helpful for the differentiation of small hepatic abscess from metastasis.

Liver abscess in the caudate lobe caused by a fishbone and treated by laparoscopy: a case report.

BACKGROUND: Ingestion of fish bones leading to gastric perforation and inducing abscess formation in the caudate lobe of the liver is very rare. CASE PRESENTATION: A 67-year-old man presented to our hospital with a 2-day history of subxiphoid pain. There were no specific symptoms other than pain. Laboratory tests showed only an increase in the number and percentage of neutrophils. Contrast-enhanced Computerized tomography (CT) of the abdomen showed two linear dense opacities in the gastric cardia, one of which penetrated the stomach and was adjacent to the caudate lobe of the liver, with inflammatory changes in the caudate lobe. We finally diagnosed his condition as a caudate lobe abscess secondary to intestinal perforation caused by a fishbone based on the history and imaging findings. The patient underwent 3D laparoscopic partial caudate lobectomy, incision and drainage of the liver abscess, and fishbone removal. The procedure was successful and we removed the fishbone from the liver. The patient was discharged on the 9th postoperative day without other complications. CONCLUSIONS: Liver abscess caused by foreign bodies requires multidisciplinary treatment. Especially when located in the caudate lobe, we must detect and remove the cause of the abscess as early as possible. Foreign bodies that perforate the gastrointestinal tract can penetrate to the liver and cause abscess formation, as in this case. When exploring the etiology of liver abscesses, we should investigate the general condition, including the whole gastrointestinal tract.

Non-Resolving Perihepatic Abscess Following Spilled Gallstones Requiring Surgical Management.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholelithiasis and is among the most frequently done procedures in United States. Spillage of gallstones occurs in up to 30 percent of these procedures and is associated with rare but important complications including abscess formation. CASE DESCRIPTION: We present a case of 44-year-old man with a peri-hepatic abscess developed three years after a laparoscopic cholecystectomy. Multiple percutaneous drainages and antibiotic courses had failed to provide a definitive resolution. CT scan showed signs of a developing abscess but no stones. A diagnostic laparoscopy was performed, and multiple retained stones were visualized. It was converted to open laparotomy and the abscess was drained along with resection of portions of liver and diaphragm. The patient remained vitally stable with no fever spikes following the procedure. DISCUSSION: Spillage of gallstones should be seriously considered in all patients presenting with peri-hepatic abscess with a history of previous LC, even if the imaging studies do not provide evidence of stones. Percutaneous drainage and antibiotics may provide temporary relief, but a surgical intervention is often the definitive management.

[A case of fibrolamellar hepatocellular carcinoma mimicking a liver abscess].

A 23-year-old woman was presented with fever and epigastric pain. Contrast enhanced computed tomography revealed a 40mm mass in the lateral segment. Blood tests showed the elevation of WBC and CRP. With the diagnosis of liver abscess, the antibiotics were administered, and the clinical findings were promptly improved. One year later, she complained of the same symptoms, and the mass had increased to 50mm in diameter. Percutaneous liver biopsy led to the diagnosis of fibrolamellar hepatocellular carcinoma.

[A case of abscess-associated hepatocellular carcinoma with massive lymphoid cell infiltration].

A 76-year-old Japanese man was admitted to our hospital with chills and fever. Computed tomography revealed a 10-cm cystic tumor with peripheral ring enhancement in the left lobe of the liver and several small low-density areas with early peripheral enhancement in both lobes. The large liver mass was diagnosed as a pyogenic abscess and treated with antibiotics. However, elevation of the tumor marker, PIVKA-II, raised the possibility of hepatocellular carcinoma. A fine-needle aspiration biopsy was performed, and malignant hepatic cells were identified. The patient underwent left hepatectomy. Histological analyses of the resected surgical specimen confirmed necrotic liver abscess and residual hepatocellular carcinoma with massive lymphoid cell infiltration. Immunohistochemical analyses revealed that the lymphoid cells were positive for CD3 and CD8. The PIVKA-II level returned to normal after surgery and the hepatic lesions disappeared within 10 months. These findings suggest that the liver abscess stimulated cancer immunity, resulting in the proliferation of cytotoxic T lymphocytes and, subsequently, tumor regression.