Successful Use of Colistin Monotherapy as Outpatient Parenteral Antibiotic Therapy for XDR Acinetobacter Hepatic Abscesses.

Acinetobacter baumannii is naturally resistant to several classes of antibiotics and readily develops further resistance mechanisms under antibiotic pressure. For patients infected with extremely drug-resistant organisms, effective antibiotic treatments are intravenous and often require inpatient hospitalization for monitoring and dose adjustment. A 31-year-old active duty service member, stationed in Southeast Asia, sustained thermal burns from an electrical arc injury to over 40% of his total body surface area. His hospital course was complicated by multiple extensively drug resistant (XDR) A. baumanii infections including bacteremia and hepatic abscesses. To facilitate discharge to his family, his hepatic abscesses were treated successfully as an outpatient with several weeks of parenteral colistin monotherapy. With regular renal function testing, his dosages were held and/or adjusted to compensate for acute kidney injuries, and he was successfully cleared of his infection. Up to 50% of A. baumannii isolates in American hospitals, including major DOD facilities, are carbapenem resistant. As a result, historically last-line therapies, such as polymyxins, are increasingly used as treatment. New dosing guidance is emphasized to minimize renal toxicities. This case demonstrates the ability to administer parenteral colistin as an outpatient under close supervision.

Primera manifestación oftalmológica de una sepsis por Klebsiella. Importancia de la sospecha diagnóstica precoz / Endogenous endophthalmitis as a first clinical manifestation of Klebsiella sepsis. The importance of an early diagnosis

Caso clínico: Paciente diabético que desarrolla una uveítis unilateral con un foco de coriorretinitis en el ojo derecho asociada a fiebre y disminución de la visión. Sospechándose una endoftalmitis endógena se realizaron pruebas complementarias encontrándose abscesos hepáticos con biopsia positiva para Klebsiella. La afectación ocular se fue resolviendo gracias a antibioticoterapia intravenosa y al drenaje percutáneo de los abscesos. Conclusión: La endoftalmitis endógena por Klebsiella es un hallazgo poco frecuente con consecuencias graves. Un diagnóstico y un tratamiento antibioticoterápico tempranos pueden mejorar el cuadro aunque la visión resultante suele ser pobre(AU)

Case report: A diabetic patient who developed a unilateral uveitis with a chorioretinitis patch in his right eye associated with decreased visual acuity and fever. Endogenous endophthalmitis was suspected and complementary tests were performed, finding hepatic abscesses with Klebsiella isolation in the biopsy. The ocular disorder slowly improved with intravenous therapy and guided percutaneous liver drainage. Conclusion: Endogenous Klebsiella endophthalmitis is an uncommon condition with severe complications. An early diagnosis and aggressive antibiotic therapy can ameliorate the final course but the visual outcome still remains poor(AU)

Hepatic and biliary damage after transarterial chemoembolization for malignant hepatic tumors: incidence, diagnosis, treatment, outcome and mechanism.

OBJECTIVE: To provide an overview of recent studies on transarterial chemoembolization-related hepatic and biliary damage (TRHBD) in patients with malignant hepatic tumors (MHT) and to explore the reasons for TRHBD. METHODS: Literature on the treatments for MHT by TACE was sought in PubMed and the related information was summarized. RESULTS: TRHBD is found to occur in the hepatic parenchymal cells, biliary tree and blood-vascular system. The damage is mainly due to ischemia resulting from embolic materials such as gelatin sponge and lipiodol. In addition, clinicians' skill levels in non-superselective catheterization, the health condition of the patients, and the chemical agents used may also be related to the damage. Most of the deterioration can be reversed if the patients are diagnosed and treated properly and promptly. CONCLUSIONS: Understanding the mechanisms of TRHBD more comprehensively is helpful in developing effective methods for prevention and treatment.

Liver Abscess and Empyema due to Lactococcus lactis cremoris

Lactococcus lactis cremoris infections are very rare in humans. We experienced liver abscess and empyema due to L. lactis cremoris in an immunocompetent adult. A 42-yr-old man was admitted with fever and abdominal pain. Abdominal computed tomography (CT) revealed a liver abscess and chest CT showed loculated pleural effusion consistent with empyema. L. lactis cremoris was isolated from culture of the abscess material and blood. The patient was treated with pus drainage from liver abscess, video-assisted thoracoscopic decortications for empyema, and antibiotics including cefotaxime and levofloxacin. The patient was completely recovered with the treatment. To our knowledge, this is the first report of a L. lactis cremoris infection in Korea.

Complicated sigmoid diverticulitis.

In medical practice, the colonic diverticulitis diagnosis is easy, based especially on a barium enema and an inferior digestive endoscopy, but the diverticulitis complications, especially metastatic infections, raise serious positive and differential diagnosis problems. We present the case of a 51 year old male who comes with hepatomegaly and multiple hepatic formations, in deteriorating clinical condition, context suggestive of secondary metastasis, but after investigation it was demonstrated they were of infectious nature, from a sigmoidian diverticulitic abscess. In this case, the hepatic biopsy was appropriate and it represented an important moment in the management of the patient.

Liver abscess after percutaneous radiofrequency ablation for hepatocellular carcinomas: frequency and risk factors.

OBJECTIVE: The purpose of this study was to clarify the frequency and risk factors of liver abscess formation after percutaneous radiofrequency ablation in patients with hepatocellular carcinoma. MATERIALS AND METHODS: Over a 4-year period, 603 patients with 831 hepatocellular carcinomas measuring 5 cm or less in maximum diameter who underwent a total of 751 percutaneous radiofrequency ablation procedures were enrolled in this study. We retrospectively reviewed the medical records and analyzed the overall frequency of liver abscess, risk factors for abscess, and clinical features of the patients. The relationships between liver abscess and potential risk factors were analyzed using either generalized estimating equations or multiple logistic regression analysis. RESULTS: Liver abscess developed in 14 tumors of 13 patients after 13 (13/751 [1.7%]) ablation procedures. Generalized estimating equations and multiple logistic regression analysis of various potential risk factors revealed that preexisting biliary abnormality prone to ascending biliary infection (p = 0.0088), tumor with retention of iodized oil from previous transcatheter arterial chemoembolization (p = 0.040), and treatment with an internally cooled electrode system (p = 0.016) were associated with a significant risk of liver abscess formation. No patient died of liver abscess, and all successfully recovered from liver abscess with parenteral antibiotics and percutaneous clearance of pus. CONCLUSION: Although liver abscess formation was infrequent in patients who underwent percutaneous radiofrequency ablation for hepatocellular carcinoma, the patients with significant risk factors-preexisting biliary abnormality prone to ascending biliary infection, tumor with retention of iodized oil, and treatment with an internally cooled electrode system-for liver abscess formation should be closely monitored after treatment.

The importance of Bi-Digital O-Ring Test in the treatment of multiple hepatic abscesses: a case history.

The Bi-Digital O-Ring Test has been very useful in the identification of bacterial and viral infections, as well as other etiological agents, in difficult clinical cases. Case report of a patient with multiple hepatic abscesses (pylephlebitis induced hepatic abscess is the most difficult abscess to treat), in which the etiological agent was suggested through Bi-Digital O-Ring Test with excellent clinical evolution after modification of previously ineffective multi anti-microbial treatment is presented. 45 years old, female with a history of pain at right hypochondria for 15 days, with jaundice, oscillating fever and shivering. Computerized tomography showed liver with multiples nodules in the parenchyma with additional appendicitis. An appendectomy was performed with drainage of intra abdominal abscesses. Treatment with metronidazol, ceftazidim and amicacine was performed with no improvement while the general condition of the patient was deteriorating progressively in the following 3 weeks. Bi-Digital O-Ring Test was then performed to determine the etiological agent and the drug compatibility test among effective antimicrobial agents. Based on the Bi-Digital O-Ring Test, the main etiological agent was found to be Enterobacter aerogenes. Amongst the three antibiotics that were being used, only metronidazol was effective and the other 2 was cancelled its effect. Based on Bi-Digital O-Ring Test findings two new antibiotics (cefadroxil and imipenen), were added to metronidazol and additional cilantro tablets by Hayashibara, Japan was given, and Selective Drug Uptake Enhancement Method performed, with excellent clinical, laboratory testing and tomography improvement within 10 days. Bi-Digital O-Ring Test suggested the etiological agent, and effective and mutually compatible antibiotics for treating the abscesses which resulted in a good clinical evolution, characterized by relief of fever and reduction of the hepatic abscesses in a short period and followed complete disappearance of hepatic abscess.

Gas venoso hepatoportal secundario a diverticulitis aguda / Hepatoportal venous gas secondary to acute diverticulitis

La presencia de gas en el sistema venoso hepatoportal es una entidad muy infrecuente que se asocia a cuadros abdominales catastróficos, con una mortalidad del 75 por ciento. Se origina por la presencia de gérmenes productores de gas y/o comunicación directa del gas intraluminal con el espacio portal en casos de lesión mucosa -asociada o no a necrosis intestinal- u obstrucción intestinal. El tratamiento ha de ser combinado e intensivo, con reanimación, antibioterapia y cirugía. Se presenta un cuadro secundario a una etiología excepcionalmente citada, como es la diverticulitis aguda perforada, que inicialmente respondió al tratamiento agresivo médico y quirúrgico, aunque la evolución final fue el fallecimiento del paciente (AU)

Giant hepatic biloma following transcatheter oily chemoembolization in a patient with hepatic metastases from malignant pheochromocytoma.

A 48-year-old woman developed hepatic metastases from malignant pheochromocytoma resected 8 years previously. Angiography revealed multiple tumor stains in the liver. Transcatheter oily chemoembolization using styrenomaleic acid neocarzinostatin and iodized oil was performed. The patient complained of severe right upper quadrant pain immediately following the transcatheter oily chemoembolization. Necrotizing cholecystitis developed on the 4th day post-transcatheter oily chemoembolization, hepatic infarction on the 12th day, and a biloma on the 19th day. Despite the administration of antibiotics and percutaneous transhepatic drainage, neither the volume of drainage nor the size of the biloma decreased. Biliary reconstruction was performed using a metallic stent, which decreased the size of the biloma.

[Pyogenic liver abscess. A descriptive study of 35 cases]. / Absceso hepático piógeno. Estudio descriptivo de 35 casos.

Thirty-five patients with pyogenic hepatic abscess (PHA) attended over 13 years in a general hospital were studied. The aim of the study was to know the usefulness of the performance of opaque enema in patients with cryptogenic PHA and the prognosis of the patients treated with only antibiotics. The most frequent clinical and analytical manifestations were fever and leukocytosis. Other less frequent findings were abdominal pain, hepatomegaly and elevated alkaline phosphatase and aspartate aminotransferase levels. One third of the patients presented radiologic alterations at the base of the right hemithorax. Colon studies in the patients with cryptogenic PHA performed to discard another origin of the abscess demonstrated very low profitability. Abdominal echography showed adequate sensitivity (0.85) in the diagnosis of PHA and allowed percutaneous drainage to be performed in most of the cases. The patients who were treated with only antibiotics presented a significantly worse prognosis than those treated with antibiotics and drainage (p = 0.03). Drainage of the PHA also allowed a decrease in the length of fever duration.

Liver abscess as the initial manifestation of colonic Crohn's disease: report of a case.

Liver abscess is a rare complication of Crohn's disease and in most of the reported cases, the diagnosis of Crohn's disease preceded that of liver abscess. We report herein a case in which a liver abscess was the initial clinical manifestation of Crohn's disease in a 36 year old man who presented with high fever and weakness. The diagnosis of liver abscess was established by abdominal ultrasonography, computed tomography and an arterial blood culture. The abscess was resolved with antibiotic therapy alone and during the drug therapy, a barium enema examination was performed which revealed a stricture at the transverse colon. Resection of the transverse colon was performed and macroscopic and microscopic examination of the resected specimen established the diagnosis of Crohn's disease. The liver abscess was thus speculated to be secondary to the inflamed bowel. Although rare, Crohn's disease should be included in the differential diagnosis of diseases causing liver abscess.

Tratamiento quirúrgico de los abcesos hepáticos no amibianos: diez años de experiencia en el Instituto Nacional de la Nutrición Salvador Zubirán / Surgical treatment of non-amebic liver abscess: 10 years' experience at the Instituto Nacional de Nutrición Salvador- Zurbirán

Se revisan 18 casos de abscesos hepáticos de etiológia no amibiana que fueron sometidos a tratamientos quirúrgico de 1976 a 1985. Las manifestaciones clínicas principales fueron fiebre, dolor abdominal, hepatomegalia dolorosa e ictericia. Las alteraciones de laboratorio más importantes fueron leucocitosis con neutrofilia, elevación de la fosfatasa alcalina, y elevación mínima de transaminasas. Las indicaciones quirúrgicas más relevantes fueron síndrome abdominal agudo, condiciones tóxicas graves y falta de respuesta al tratamiento médico antiamibiano. El abordaje quirúrgico en dieciseis pacientes se realizó por laparotomía, y en los dos pacientes restantes por punción percutánea. Trece pacientes tuvieron absceso único y cinco tuvieron abscesos único y cinco tuvieron abscesos múltiples. La mortalidad operatoria fue del 39% y la causa principal fue sepsis

Successful single antibiotic therapy in Actinomyces septicemia and liver abscess.

We are reporting on a 36-year-old man with septicemia and a liver abscess due to Actinomyces sp. The infection was most probably acquired while eviscerating a deer he had shot. The possibility of an infection involving Actinomyces bovis is discussed. The liver abscess was diagnosed on the basis of non-invasive procedures. Therapy consisted of high-dose penicillin without surgical drainage of the abscess. The infection did not recur during the three-and-a-half year follow-up period. No previous reports of successful antibiotic therapy for actinomycotic liver abscess without surgical procedures are known.

Hepatic abscesses in diverticulitis.

Liver abscess is an uncommon but potentially lethal complication of diverticulitis. Either may be present in an occult form. We present two cases to illustrate the diagnostic and therapeutic problems created by these occult presentations. A high index of suspicion and an aggressive diagnostic approach are necessary to ensure early diagnosis and proper treatment. Barium enema should be done in patients with liver abscesses when there is no obvious source for the abscess. Intraoperative evaluation of the liver, including needle aspiration of any suggestive areas, should be done in all patients operated upon for complicated diverticulitis. Patients with diverticulitis and abnormal results of liver function tests should have liver scan or abdominal sonography.

The use of multiple radionuclide imaging to differentiate the focal intrahepatic lesion.

Thirty-five patients with various focal intrahepatic lesions were evaluated with multiple radionuclides. Comparison of the blood pool scans with angiography and histology demonstrated an excellent correlation of these studies. Diagnostic accuracy was improved by separating the blood and pool scans into 3 categories. Each category suggested, at most, one further study to provide specific diagnostic information. Thus, by utilizing 3 radiopharmaceuticals, one can be more specific in preoperative diagnoses.