Case report of an unusual hepatic abscess caused by Actinomyces odontolyticus in a patient with human immunodeficiency virus infection.

BACKGROUND: Actinomyces odontolyticus is not commonly recognized as a causative microbe of liver abscess. The detection and identification of A. odontolyticus in laboratories and its recognition as a pathogen in clinical settings can be challenging. However, in the past decades, knowledge on the clinical relevance of A. odontolyticus is gradually increasing. A. odontolyticus is the dominant oropharyngeal flora observed during infancy [Li et al. in Biomed Res Int 2018:3820215, 2018]. Herein we report a case of severe infection caused by A. odontolyticus in an immunocompromised patient with disruption of the gastrointestinal (GI) mucosa. CASE PRESENTATION: We present a unique case of a patient with human immunodeficiency virus infection who was admitted due to liver abscess and was subsequently diagnosed as having coinfection of A. odontolyticus, Streptococcus constellatus, and Candida albicans during the hospital course. The empirical antibiotics metronidazole and ceftriaxone were replaced with the intravenous administration of fluconazole and ampicillin. However, the patient's condition deteriorated, and he died 3 weeks later. CONCLUSION: This report is one of the first to highlight GI tract perforation and its clinical relevance with A. odontolyticus infection. A. odontolyticus infection should be diagnosed early in high-risk patients, and increased attention should be paid to commensal flora infection in immunocompromised individuals.

The Importance of Autopsy in a Case of Digestive Perforation Undetected by Postmortem Computed Tomography.

ABSTRACT: Cases of foreign body ingestion in the forensic literature are mainly described in children or psychiatric patients. Postmortem imaging can detect most foreign bodies, but its sensitivity depends, among other things, on the type of item and its location. In some cases, the ingestion of foreign bodies can remain unnoticed and have serious consequences for the patient. We describe the case of a patient who died in a psychiatric seclusion room with no obvious cause and for whom a forensic autopsy was requested. Further investigations showed the existence of a subdural hematoma associated with a midline shift, secondary to a skull fracture that was considered to be the cause of death. Toxicological analyses identified in blood several drugs, including diazepam (24 ng/mL) and its major metabolite nordazepam (24 ng/mL), propranolol (57 ng/mL), paliperidone (9 ng/mL), and loxapine (620 ng/mL). The forensic autopsy revealed the existence of a gastrointestinal perforation after the ingestion of a plastic teaspoon, which the postmortem CT scan had failed to detect. Although technological advances continue to assist the forensic pathologist in his diagnosis, autopsy still has a leading role in forensic investigations and does not yet seem to be replaceable by imaging techniques alone.

Common Infections and Target Organs Associated with Chronic Granulomatous Disease in Iran.

Recurrent severe bacterial and fungal infections are characteristic features of the rare genetic immunodeficiency disorder chronic granulomatous disease (CGD). The disease usually manifests within the first years of life with an incidence of 1 in approximately 200,000 live births. The incidence is higher in Iran and Morocco where it reaches 1.5 per 100,000 live births. Mutations have been described in the 5 subunits of NADPH oxidase, mostly in gp91phox and p47phox, with fewer mutations reported in p67phox, p22phox, and p40phox. These mutations cause loss of superoxide production in phagocytic cells. CYBB, the gene encoding the large gp91phox subunit of the transmembrane component cytochrome b558 of the NADPH oxidase complex, is localized on the X-chromosome. Genetic defects in CYBB are responsible for the disease in the majority of male CGD patients. CGD is associated with the development of granulomatous reactions in the skin, lungs, bones, and lymph nodes, and chronic infections may be seen in the liver, gastrointestinal tract, brain, and eyes. There is usually a history of repeated infections, including inflammation of the lymph glands, skin infections, and pneumonia. There may also be a persistent runny nose, inflammation of the skin, and inflammation of the mucous membranes of the mouth. Gastrointestinal problems can also occur, including diarrhea, abdominal pain, and perianal abscesses. Infection of the bones, brain abscesses, obstruction of the genitourinary tract and/or gastrointestinal tract due to the formation of granulomatous tissue, and delayed growth are also symptomatic of CGD. The prevention of infectious complications in patients with CGD involves targeted prophylaxis against opportunistic microorganisms such as Staphylococcus aureus, Klebsiella spp., Salmonella spp. and Aspergillus spp. In this review, we provide an update on organ involvement and the association with specific isolated microorganisms in CGD patients.

[Polymicrobial liver abscesses and pleural empyema in a 40-year-old male after tooth extraction and closed periodontal treatment: A case report]. / Polymikrobielle Leberabszesse und Pleuraempyem bei einem 40-jährigen Mann nach Zahnextraktion und geschlossener Parodontitis-Behandlung: Ein Fallbericht.

We report on a 40-year-old patient who presented with fever, right upper abdominal pain, right-sided chest pain and acute dyspnea. Imaging revealed several liver abscesses, as well as extensive right pleural empyema. Sixteen weeks previously, the patient underwent tooth extraction of the third molars (18, 28, 38, 48) and a first molar (46), and systematic closed periodontitis treatment. Four different species of the physiological microbiota of the oral cavity were detected in the pleura or liver abscess punctate (Streptococcus anginosus, Streptococcus constellatus, Actinomyces odontolyticus, Prevotella denticola). An underlying immune defect was ruled out. Ultrasound-guided drainage of liver abscesses and surgical treatment of pleural empyema by video-assisted thoracoscopy (VATS) and insertion of thoracic suction drains was performed, accompanied by targeted antibiotic therapy. Over a course of 6 weeks, the patient recovered completely. The case report illustrates severe infectious side effects of major dental interventions, and it critically summarizes current dental guideline recommendations on peri-interventional antimicrobial therapy. Therefore, a good clinical follow up after major tooth extractions is imperative.

Hepatic abscess due to Dialister pneumosintes - A case report.

Dialister pneumosintes is an obligate anaerobic Gram-negative rod associated with infections of the oral cavity. We report on a previously healthy, 51-year-old woman who presented with a liver abscess caused by Dialister pneumosintes as a complication of a dental abscess. The microorganism was identified by using a broad-range bacterial 16S rRNA gene PCR in the liver exudate. The patient was cured after abscess drainage and 4-week antibiotic treatment. Our case highlights the importance of a good history and physical examination when taking care of patients admitted for pyogenic liver abscess.

A liver abscess secondary to a toothpick: a rare complication of accidental foreign body ingestion.

Perforation of the gastrointestinal tract caused by the ingested foreign bodies and subsequent hepatic abscess formation is uncommon. Early diagnosis is difficult and the treatment is mainly surgical.

Liver Abscess due to Streptococcus constellatus in an Immunocompetent Adult: A Less Known Entity.

BACKGROUND: Pyogenic liver abscesses (PLAs) are an uncommon, but potentially life threatening infection. We report a case of PLA due to Streptococcus constellatus, a member of the Streptococcus anginosus group (SAG) bacteria, commonly found as commensals of the oropharyngeal, gastrointestinal and genitourinary flora. CASE: The patient, a 42-year-old man with no premorbidities, non-smoker and non-alcoholic, presented to our hospital with high-grade fever associated with chills and rigors and right upper quadrant pain of one month duration. Culture of the ultrasound-guided liver aspirate yielded a pure growth of S. constellatus subspecies constellatus identified by conventional biochemical tests. In a standard antimicrobial disk-diffusion test, the isolate was susceptible to cefepime, cefotaxime, ceftriaxone, vancomcyin, levofloxacin, clindamycin and linezolid. Treatment with parenteral ceftriaxone alongwith appropriate surgical management led to resolution of the abscess with no recurrence of infection at three months follow-up. CONCLUSIONS: The pathogenic potential of SAG has generally been disregarded because of the commensal nature of these microorganisms; however, streptococci belonging to this group have been increasingly reported as relevant pathogens in abscesses and blood cultures. An underlying condition, such as diabetes, cirrhosis or cancer or some medical manipulation, such as dental extraction, acupuncture, or hemorrhoidectomy is associated with the majority of patients with SAG abscess. However, the present case highlights the need to include S. constellatus and other members of the SAG while investigating for etiology of PLA, even in immunocompetent adults.

A case of liver abscess with systemic infection caused by Fusobacterium.

A 43-year-old man was admitted to our hospital because of an abnormal shadow on chest X-ray. Blood testing showed elevated levels of C-reactive protein and white blood cells. Computed tomography revealed multilocular masses of the right hepatic lobe, reticulonodular shadowing on both lungs, left kidney masses, and aortic arch aneurysm. Fusobacterium nucleatum was isolated from the hepatic abscess after percutaneous transhepatic drainage. Because of severe dental caries, he was diagnosed with liver abscess caused by dental infection with F. nucleatum. Administration of cefmetazole and meropenem was not effective; however, he showed remarkable improvement after treatment with metronidazole and continuous drainage.

Endoscopic inside stent placement is suitable as a bridging treatment for preoperative biliary tract cancer.

BACKGROUND: Endoscopic biliary stenting (EBS) is one of the most important palliative treatments for biliary tract cancer. However, reflux cholangitis arising from bacterial adherence to the inner wall of the stent must be avoided. We evaluated the use of EBS above the sphincter of Oddi to determine whether reflux cholangitis could be prevented in preoperative cases. METHODS: Fifty-seven patients with primary biliary tract cancer were retrospectively recruited for the evaluation of stent placement either above (n = 25; inside stent group) or across (n = 32; conventional stent group) the sphincter of Oddi. We compared the stent patency periods prior to the time of surgical resection. RESULTS: The preoperative periods were 96.3 days in the conventional stent group and 96.8 days in the inside stent group (P = 0.979). Obstructive jaundice and/or acute cholangitis occurred in 7 patients (28.0%) in the inside stent group and in 15 patients (46.9%) in the conventional stent group during the preoperative period (P = 0.150). The average patency periods of the stents were 85.2 days (range, 13-387 days) for the inside stent group and 49.1 days (range, 9-136 days) for the conventional stent group (log-rank test: P = 0.009). The mean numbers of re-interventions because of stent occlusion were 0.32 for the inside stent group and 1.03 for the conventional stent group (P = 0.026). Post-endoscopic retrograde cholangiopancreatography complications occurred in 2 patients in the inside stent group and 4 patients in the conventional stent group (P = 0.516). Postoperative liver abscess occurred in 1 patient in the inside stent group and 5 patients in the conventional stent group (P = 0.968). Inside stent placement was the only significant preventative factor associated with stent obstruction based on univariate (hazard ratio [HR], 0.286; 95% confidence interval [CI], 0.114-0.719; P = 0.008) and multivariate (HR, 0.292; 95% CI, 0.114-0.750; P = 0.011) analyses. CONCLUSION: Temporary plastic stent placement above the sphincter of Oddi is a better bridging treatment than conventional stent placement in preoperative primary biliary tract cancer.

Hepatic abscess linked to oral actinomycetes: a case report.

Organ abscesses are rare, life-threatening complications that can be caused by bacteremia from oral infections. Metastatic infection is a well-established concept. Dental and periapical infections can cause infections in distant organs and tissues. The frequency of these systemic infections and systemic diseases is open to debate, as some patients are more susceptible to infections than others. This article presents the case report of a 52-year-old woman who was hospitalized with a hepatic abscess after a routine periodontal maintenance procedure. The patient had poor oral health, involving several nonrestorable teeth, multiple failed endodontic treatments, and asymptomatic chronic periapical pathologies. Her dental history included previous diagnoses of moderate generalized chronic periodontitis and advanced localized periodontitis. It was possible that bacteremia developed during her most recent dental treatment, leading to the hepatic abscess. Systemic antibiotic therapy, drainage of the hepatic abscess, and oral rehabilitation resulted in complete recovery.

[A case of liver abscess due to Streptococcus anginosus infection secondary to a dental extraction].

A 74-year-old man was referred to our hospital because of a high fever. He had undergone a dental extraction about 1 month prior to admission because of apical periodontitis. Imaging study revealed liver abscess lesions. Infection with Streptococcus anginosus was confirmed using both stab and blood culture. An adequate selection of antibiotics was administered, and a good outcome was obtained. There have been no case reports of liver abscess caused by intraoral commensal flora related to dental extraction in healthy adults. This case shows that liver abscesses can occur secondary to dental extractions, even in healthy adults.

[A case of multiple liver abscesses associated with Streptococcus salivarius in a patient with chronic periodontitis].

Streptococcus salivarius is an oral commensal bacterium that rarely causes disease in humans. Here, we report a case of liver abscess associated with S. salivarius in a 41-year-old woman who presented with continuous abdominal discomfort, fatigue, and fever. She was diagnosed with multiple liver abscesses; she underwent percutaneous transhepatic abscess drainage. Thereafter, S. salivarius was isolated in all bacterial cultures of the drained abscesses, and it was sensitive to penicillins. She made a good recovery after treatment. In the absence of an infective source other than chronic periodontitis, the cause of liver abscesses was attributed to oral S. salivarius. S. salivarius is a normal oral commensal, and oral commensals must be considered if the infective origin of liver abscess cannot be determined.

Unexpected death from hepatic abscess 16 months after toothbrush ingestion.

The development of a hepatic abscess secondary to foreign body (FB) ingestion remains rare in forensic practice. Herein, we present a case of a prisoner who died in the hospital and a forensic autopsy was performed to confirm the cause of death. A 14.5-cm-long toothbrush handle was found in the duodenum and had penetrated the right lobe of the liver, consistent with the repeated abdominal pain in his clinical history. The clinical history and investigation confirmed that he had ingested the toothbrush handle 16 months prior. This case highlights a rare complication of intentional ingestion of foreign bodies, and pathologists should be aware of this rare entity which links hepatic abscess and FB ingestion.

Successful endoscopic treatment of huge infected biloma and hepatic abscess after endoscopic ultrasound-guided hepaticogastrostomy with brain abscess.

A 77-year-old woman with obstructive jaundice due to pancreatic head tumor was admitted to our hospital for biliary drainage. Transpapillary biliary drainage was attempted using endoscopic retrograde cholangiopancreatography; however, the catheter could not be inserted into the bile duct. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was conducted using a 7-Fr plastic stent. Fever and cognitive dysfunction were observed 73 days after EUS-HGS. Abdominal-computed tomography (CT) showed a huge biloma and a liver abscess. On admission, an uncovered metal stent was applied to the biliary obstruction site of the distal bile duct using an antegrade stenting technique, and the plastic hepaticogastrostomy stent was substituted with a new one. On the second day, two double-pigtail plastic stents were inserted into the biloma, and one into the liver abscess. Head CT and magnetic resonance imaging revealed a brain abscess in the right cerebral frontal lobe. Serum white blood cell count and C-reactive protein level, and the state of consciousness, improved with antibiotic administration. Biloma and liver abscess almost disappeared on CT 38 days after admission. The brain abscess also improved, and the patient was discharged from the hospital 48 days after admission. Endoscopic ultrasound-guided biloma drainage is helpful because self-removal of the drainage tube and reduced activities of daily living are unlikely to occur.

Liver abscess due to Actinomyces odontolyticus in an immunocompetent patient.

Liver abscess caused by Actinomyces odontolyticus is rarely reported. We report an immunocompetent patient who developed A. odontolyticus liver abscess, and was successfully treated with antibiotics for 6 weeks and abscess drainage. The isolate could not be identified accurately by one commercial biochemical method and was documented to species level by partial sequencing analysis of 16S rRNA genes.

Use of N-acetyl cysteine to retrieve entrapped Malecot catheter in liver: an old agent for a novel application.

Percutaneous catheter drainage is one way of treating large liver abscesses that are partially liquefied or have thick pus. Apart from discomfort, severe pain, inflammation or frank cellulitis at the insertion site, and sometimes catheter dislodgement, failure to retrieve a catheter is unusual. This may occur either due to fibrous tissue securing the catheter or when inspissated secretions prevent the catheter tip from straightening. N-acetyl cysteine is a mucolytic and exerts action in many parts of the body such as the mouth, throat and lungs. We report successful removal of a catheter stuck in the liver using this substance.

Liver abscess due to Fusobacterium species detected on ultrasonography: a case report.

An oral infection harboring Fusobacterium species can gain entrance to the liver via hematogenous spread in the form of septic embolus, and can thereby cause abscesses. Such spread, described as Lemierre syndrome, is life threatening. We present such a case history of a man in his mid-40s, who presented with infection and Fusobacterium liver abscess with an acute fulminant disease course. The initial diagnosis was arrived at by ultrasound imaging and blood investigations. He was treated with antibiotics, ultrasound-guided liver abscess drainage, and extraction of the infected molar tooth. He was discharged 6 weeks after admission. To date, there have been no reports describing the ultrasound images of a Fusobacterium liver abscess in detail. Hence, we herein present the ultrasound images of a Fusobacterium liver abscess.