Clinical Case Conference

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Clinical Case Conference

• Munshi Moyenuddin, M.D.,Ph.D.
• Section of Infectious Diseases
• 22 April, 2002

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Case 1

• A 23 y/o WM presented with fever, RUQ-abdominal
  pain, nausea, and vomiting for 4-days. He c/o
  difficulty in sleeping due to abd pain, and
  inability to tolerate p.o. intake. He also noted
  some diarrhea on the day of presentation. He
  denied any recent travel or sick contact.
• PMHx- Asthma. PSHx- Knee surgery 6-years ago.
• Soc Hx- Denied tobacco and recreational drugs,
  but admitted occasional ETOH intake with friends.

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Case 1 (contd)

• Allergy- none. Home meds- albuterol prn.
• PE T-101, P-143, R-24, BP-106/86, Pox-95 in RA
• Gen- mod unconfortable obese white male.
• HEENT- PERRLA, no icterus, no oropharyngeal
  exudate.
• CV and lung exam- unremarkable.
• Abdomen- soft, RUQ tenderness, BS,
  hepatomegaly-5cm below costal margin, no
  guarding.
• Ext- no edema/ c/c.

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Case 1 (contd)

• Total Bili-1.9, alk phos-128, AST-161, ALT-249
  wbc-19.8,Hg-14.4, plt-281, Cr-1.5
• UA- 2 wbc, nitrite, many bacteria.
• Abdominal Ultrasound- negative for cholecystitis,
  gallbladder stone, or ductal dilatation.
• Patient was admitted. Blood Cxs were drawn.
  Ciprofloxacin was started IV. GI consult was
  obtained.
• CT of abdomen was done.

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Case 1 (contd)

• CT findings11.8 x 8.4 cm enhancing lesion within
  the dome of the liver. The lesion is
  multiloculated. The liver is enlarged at 24 cm in
  cranio-caudal dimension. The spleen is without
  any focal lesion.Bilateral pleural effusion.
• Pip/tazo and metronidazole were subsequently
  started.
• Blood cultures were negative.

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Case 1 (contd)

• Pt had an episode of -sided chest pain and SOB.
• MRI of abd- large lesion 13.5cm x 9.4cm x 12.7cm
  within the lobe of the liver, suggestive of
  abscess.
• CT-guided percutaneous drain was placed to drain
  the abscess.
• Pt continued to have abd pain and fever.
• Repeat CT-scan after a week- persistence of
  abscess in the liver and large fluid collection
  in chest.

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Case 1 (contd)

• Exploratory laparotomy was done with drain of
  liver abscess and drain of large purulent
  material from beneath the costal margin.
• Abscess cultures- negative.
• Entamoeba histolytica serology- negative.
• Pt continued on Pip/tazo and metronidazole.
• His symptoms were improved, a rept CT showed
  complete drain of abscess, pt D/Cd after 6 weeks.

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Hepatic Abscess

• The liver is the organ most subject to the
  development of abscess.
• Altemeier et al. (Am J Surg 1973) studied 540
  intraabdominal abscesses over a 12-year period.
  Among them 26 were visceral, liver abscess made
  up of 48 of all visceral abscess.

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Hepatic Abscess

• Pathogenesis The sources may be (1) biliary, in
  which disease of the extrahepatic biliary tract
  is caused by a calculus, stricture, or malignancy
  and results in ascending cholangitis (2) portal,
  in which appendicitis, diverticulitis, or
  inflammatory bowel disease may be associated with
  acute suppurative thrombophlebitis in the portal
  venous system (3) infection in a contiguous
  structure, such as gallbladder (4) infected foci
  anywhere in the body via hepatic artery (5)
  penetrating wounds and non-penetrating trauma to
  the liver (6) cryptogenic, when no source is
  evident.

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Hepatic Abscess

• Recently, pyogenic abscess has been noted to be
  one of the infectious complications after liver
  transplantation and high frequency of abscess was
  noted in pts with chr. granulomatous disease
  (Medicine 1988). Pyogenic abscess have also been
  reported in pts with sickle cell anemia
  (Pediatrics 1971).
• Abscess caused by Entamoeba histolytica
  complicate 3 to 9 of the cases of amebic colitis
  (Am J Med 1972).

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Hepatic Abscess

• Bacteriologic Findings Pyogenic abscess is
  frequently polymicrobial (Ann Surg 1987). Enteric
  gram-negative bacilli, usually E. coli have been
  found in majority of pyogenic abscesses (Medicine
  1987). Sterile abscesses reported in some series
  about 50. When modern anerobic techniques were
  used, about 50 of all pyogenic abscesses were
  due to anerobes. These anerobes include anerobic
  gram-positive cocci, Bacteroides spp.,
  Fusobacterium spp., and Actinomyces spp. S.
  aureus or gr A Streptococci occur in 20 or less
  of the cases.

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Hepatic Abscess

• On rare occasions, Y. enterocolitica has been
  isolated (BMJ 1972).
• Candida may invade the liver as part of a
  systemic infection (Ann Int Med 1988). Most of
  the pts have leukemia
• Clinical Menifestations (1) Predominant symptoms
  of pyogenic abscess are fever and chill of
  several days to several weeks.(2) RUQ pain,
  abscess high in R-lobe may cause cough and
  pleuritic pain (3) tender hepatomegaly in 50 to
  70 of pts.(4) alkaline phosphatase is frequently
  elevated. (5) a history of diarrhea, presence of
  chest finding, lack of spiking temp more common
  with amebic.

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Hepatic Abscess

• Diagnosis (1) Scintigraph with 99mTc,
  ultrasonography, CT, and MRI are highly sensitive
  for detection. Abscess produce areas of decreased
  attenuation on CT. (2) elevation of -diaphragm,
  basilar atelectasis, R-pleural effusion, or gas
  in the abscess cavity may be noted on plain film
  of abdomen. (3) both ultrasound and CT can be
  used to guide needle aspiration for diagnostic
  and therapeutic purposes. (4) aspirated material
  should be cultured aerobically and
  anerobically.(5) amebic abscess is confirmed by
  finding E. histolytica on microscopy or culture
  of aspirate or wall of the abscess.

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Hepatic Abscess

• Prognosis Depends on the rapidity of diagnosis
  and treatment. High mortality is associated with
  advanced age and serious underlying disease. In
  the past, mortality rate from pyogenic abscess
  ranged from 24 to 79, recent studies showed
  cure rates of 88 to 100 (Lancet 1982). Amebic
  abscess that rupture into bronchi, peritoneal or
  pericardial cavity have mortality rates of 6,18
  and 30 respectively (Medicine 1977).

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Hepatic Abscess

• Treatment Some studies reported high cure rates
  with antibiotic only without percutaneous drain
  (Gastroenterology 1979 Lancet 1982), most other
  reports emphasized the necessity of some drainage
  to ensure good outcome (Am J Surg 1985 Am J
  Gastroenterol 1986). If Pts condition and fever
  dont improve in 48h of catheter drain,
  ultrasound or CT should be repeated to assess
  undrained loculations, surgery should be
  considered when fever persists for gt2 wks despite
  catheter drain and antimicrobial therapy
  (Medicine 1997).

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Hepatic Abscess

• Treatment (contd) Hepatic abscess from biliary
  obstruction, loculated or highly viscous
  abscesses require surgical incision and drainage.
• Antimicrobial therapy should be started as soon
  as the diagnosis is suspected and should be
  directed at the expected pathogens. Pathogens
  usually are similar to those involved in
  secondary peritonitis. Therapy should be
  prolonged, usually for gt1 month for multiple
  abscesses upto 4 months of therapy was
  recommended to prevent relapse (Ann Int Med 1990).

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Hepatic Abscess

• Treatment (contd) Amebic abscess is treated with
  metronidazole or dehydroemetine (Med lett 1988).
  Metronidazole is less toxic and has similar cure
  rate. Aspiration of the cavity have been
  recommended by some authors but were found
  unnecessary by others.
• A recent article studied treatment of 133
  patients in 5-hospitals 47 were subjected to
  percutaneous drain, 34 were treated by open
  drainage, and 19 received antibiotic therapy
  alone. Pts treated with antibiotic alone had a
  low rate of complication and with a treatment
  failure rate similar to that of percutaneous
  drain group (20 vs 19) (Am J Surg 2001).

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Hepatic Abscess

• Prognostic variables for a complicated clinical
  course were the presence of shock, low hemoglobin
  level, elevated prothrombin time, and
  polymicrobial infection. E. coli was the most
  commonly isolated organism. The study concluded
  that timely diagnosis and prompt treatment
  appropriate to the specific patient remains the
  standard of care.