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Klebsiella pneumoniae liver abscesses with limited antibiotic resistance have been increasing among diabetics in various geographic regions, most notably in Taiwan. Two cases of Hawaiian diabetic men with Klebsiella pneumoniae primary liver abscesses are presented as well as a brief review of the literature.
BACKGROUND/AIMS: With the advance of antibiotics and the development of newer imaging techniques, marked changes in etiology, diagnosis, treatment and prognosis of liver abscess have been reported. METHODS: We reviewed the clinical data related to 94 patients with pyogenic liver abscess. RESULTS: Of the 94 patients in the study group, the male to female ratio was 1.4:1 and the peak incidence of liver abscess was in the 7th decade. About three quarters (74.5%) of the abscesses were of unknown origin. The predominant location was in the right lobe (70.3%). Single lesion was found in 80 patients and multiple lesions in 14 patients. Pathogens were identified in 67 patients, of which Klebsiella pneumoniae (65.7%) and E. coli (16.4%) were the most common. The modalities of treatment were percutaneous drainage with antibiotics (73.4%), percutaneous aspiration with antibiotics (16.0%), or antibiotics alone (8.5%). The case fatality rate, mainly from associated underlying diseases, was 9 cases (9.6%). Associated diseases were diabetes mellitus (14.9%) and malignancy (10.6%). CONCLUSIONS: Our study revealed that the most common organism was Klebsiella pneumoniae and percutaneous needle aspiration and/or catheter drainage were safe and effective treatment modalities for pyogenic liver abscess. Prognosis was determined by the underlying condition.
Amebiasis remains one of the leading parasitic causes of death worldwide. A vaccine that prevented amebic liver abscess would significantly reduce mortality from this disease. To test the feasibility of a DNA vaccine to prevent amebic liver abscess, we immunized both mice and gerbils with plasmid DNA encoding the serine rich Entamoeba histolytica protein (SREHP). Animals receiving the SREHP DNA vaccine developed both antibody and cell mediated immune responses that recognized amebic trophozoites. A single dose of the SREHP DNA vaccine protected 80% of vaccinated mice and 60% of vaccinated gerbils from developing amebic liver abscess after direct hepatic inoculation of amebic trophozoites. Our study indicates that DNA vaccination with SREHP can provide high levels of protection against amebic liver abscess in animal models of disease.
A case of pyogenic liver abscess following successful mesenteric artery revascularization is described in a patient with acute mesenteric ischemia. Prior to revascularization, arteriography confirmed celiac and superior mesenteric artery occlusion. Occurrence of liver abscess is explained on the basis of ischemia impairing the barrier function of the intestinal mucosa, contributing to portal bacteremia that seeds ischemic or necrotic liver. In patients with acute mesenteric ischemia, sequential sonographic examination of the liver following mesenteric revascularization is advocated for early diagnosis of liver abscess if there is clinical evidence of the sepsis.
Between 1980 and 1986, 11 patients with pyogenic liver abscess were treated at the Department of Internal Medicine at the Kantonsspital St. Gallen. 2 patients underwent successful surgical drainage and 9 patients percutaneous needle aspiration or drainage. 7 were successfully treated while 2 required secondary surgical drainage. Our results suggest that percutaneous aspiration or drainage of pyogenic liver abscess should be tried before surgery is considered.
BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.
Pyogenic liver abscess are macroscopic collections of pus within the hepatic parenchyma after a bacterial infection. These infections are usually polymicrobial in nature, and in most occasions due to biliary tract diseases or cryptogenetic in origin. Monomicrobial hepatic abscess caused by Klebsiella pneumoniae are uncommon lesions in western countries. These lesions are associated with underlying diseases, particularly diabetes mellitus, and are frequently complicated with septic metastasis. We report here three cases of monomicrobial liver abscess caused by Klebsiella pneumoniae in diabetic patients, without septic metastasis and a favourable outcome.
Three previously healthy children developed nonamoebic liver abscess. Diagnosis was aided by liver scan, ultrasound assessment, and computed tomography. A variety of surgical procedures were successful in achieving proper drainage, resection of chronic lesions, and resolution of associated cholangitis.
BACKGROUND: Chronic pancreatitis uncommonly causes common bile duct stricture, and common bile duct stricture rarely leads to pyogenic liver abscess. METHODS: We describe a 51-year-old man who developed a pyogenic liver abscess after the development of a common bile duct stricture due to chronic pancreatitis. RESULTS: The patient required open drainage of the liver abscess and decompressive choledochoduodenostomy. His infection was persistent and he required percutaneous and subsequent open drainage of a second hepatic abscess. The patient died of refractory sepsis and multi-organ failure. CONCLUSIONS: The relevant English literature concerning pyogenic liver abscesses, specifically in the setting of common bile duct stricture due to chronic pancreatitis, is reviewed and discussed.
In this study of 503 consecutive cases of amebic liver abscess documented during a 21-year period, 110 (22%) were complicated by perforation. Perforation sites included pleuropulmonary structures (79 cases, 72%) subphrenic space (15 cases, 14%); and peritoneal cavity (11 cases, 10%). The less common sites were the thoracic and abdominal wall, pericardial sac, bile duct, kidney, mediastinum, colon, and right flank. Trophozoites were recovered in 29% of cases. For the rest of the cases, diagnosis was based on the clinical manifestations and the dramatic response to a therapeutic trial of amebicides. Open surgical drainage was done in 10 of 11 patients who had peritoneal perforation; 6 of them were cured and 5 died. Of 97 patients with perforation sites other than the peritoneal cavity, 64 were treated with metronidazole in addition to needle aspiration and/or percutaneous catheter drainage, and all achieved complete remission without relapse during subsequent follow-up. Of the 36 cases treated with metronidazole alone, 22 (61%) were cured. The mortality rate in the group with perforated abscess was 17% (19/110), compared with 5% (25/503) in the whole series. The results suggested that (1) amebic liver abscess can be difficult to diagnose, especially when the pathogen is not isolated; and (2) metronidazole combined with needle aspiration and/or percutaneous catheter drainage is the treatment of choice for amebic liver abscess with perforation.
PURPOSE: In an experimental pyogenic liver abscess model, the signal intensities were compared intraindividually and interindividually after the application of a new blood pool contrast agent, 24-gadolinium-DTPA (diethylenetriamine-pentaacetic acid) cascade polymer, and after the application of gadopentetate dimeglumine. METHODS: In 20 rabbits with experimentally induced liver abscesses, the relative signal intensities of the liver, abscess centre, abscess wall and portal vein were assessed before and between 30 seconds and 60 minutes after injection of a 25 mumol/kg dose of gadolinium polymer and of 100 mumol/kg of gadolinium-DTPA, respectively. Measurements were performed at 1.5 Tesla, using a head coil and a Flash-2-D sequence. RESULTS: The interindividual comparison (unpaired T-test, p < 0.05) yielded significant differences of the relative signal intensities of the abscess centre (at any time point after contrast-media application), abscess wall (between 15 and 60 minutes after contrast media application), and portal vein (between 30 seconds and 7.5 minutes after contrast media application). The interindividual comparison showed a significantly higher abscess centre-liver contrast (between 30 seconds and 12.5 minutes after contrast media application) and a significantly higher abscess wall-centre contrast (between two and 7.5 minutes after contrast media application) after the application of gadolinium polymer compared with gadopentetate dimeglumine. CONCLUSION: In this animal model, the higher abscess centre-liver contrast after the application of gadolinium polymer was the basis for a better and prolonged visibility of the abscesses, as compared with images acquired after injection of gadopentetate dimeglumine.
PURPOSE: The aim of this study was to evaluate the CT findings of amebic liver abscesses and its usefulness for treatment. METHODS: CT was performed in 51 patients with proved amebic liver abscess. CT studies were made before and after contrast injection. RESULTS: Among the 98 abscesses, 66% occurred in the right lobe. 66% of the patients presented a solitary abscess. The diameters were found between 2 cms to 15 cms. The mean was 7 cms. An enhancing wall was present in 84%; the margins were festooned in 75%, smooth in the other cases; internal septations were noted in 57%. High density material within the abscess, before injection of contrast was seen in 50%. 30% of patients had focal intra-hepatic biliary dilatation, 27% right pleural effusion, 23% peri-hepatic fluid collection. One hepatic-colic fistula and one hepato-pulmonary fistula were not suspected on U.S. examination. Percutaneous aspiration was done in 31% of the patients, when the diameter of the abscesses were more than 10 cms or when they were seen in the left lobe or when fever or pain did not disappear after treatment. CONCLUSION: CT scan may be helpful in diagnosis of amebic liver abscess at an early stage or later when a complication is suspected. CT scan can also help to indicate and safely perform a percutaneous therapeutic aspiration.
Pyogenic liver abscess is an uncommon condition which carries substantial morbidity and mortality if untreated. A review was undertaken of 31 patients who were admitted to the Royal Adelaide Hospital (RAH) between January 1980 and December 1987 and who were diagnosed as having pyogenic liver abscess. The aims of the study were to review the aetiology, current methods of investigation and treatment of the disease, and to formulate a management plan based on the findings. Hypoalbuminaemia, leukocytosis and elevated alkaline phosphatase were the most common findings. Hyperbilirubinaemia was not a usual feature. Computerised tomography (CT) scanning and ultrasound were the most useful imaging modalities in identification of the abscess. The sensitivity of CT scanning in evaluating the size of abscesses was lower than anticipated and this may lead to a higher than necessary rate of surgical drainage. A case is presented to illustrate this. Most abscesses were secondary and frequently due to extension of infection from biliary structures. Diseases causing diminished resistance to bacterial infection had a significant role in the pathogenesis. The overall mortality rate was 25%. Risk factors increasing mortality included advanced age, multiplicity of abscesses, depressed immune status and the presence of complications due to the abscess. Of patients who survived, four were treated with antibiotics alone, eleven with percutaneous drainage and antibiotics, and eight with surgery and antibiotics. We conclude that patients with hepatic abscesses should be managed initially by CT or ultrasound-guided aspiration. If pus is obtained a percutaneous drain should be inserted into the cavity and systemic antibiotics administered.(ABSTRACT TRUNCATED AT 250 WORDS)
Liver abscesses are not very frequent and those produced by Klebsiella spp. are quite exceptional. These germs have been related to the development of acute anterior uveitis (AAU) in patients whose susceptibility has been linked to HLA B27. We present a case of a female, HLA B27 negative, who developed AAU during a course of liver abscesses caused by Klebsiella pneumoniae.
Septic metastasis is a unique feature of Klebsiella pneumoniae liver abscess in Taiwan. The case we report is a vanishing K. pneumoniae liver abscess with septic metastasis of the chest wall. The initial finding of a 36 year-old male with no previous medical history, was a huge hepatic mass presented on the sonography during a physical checkup. Hepatitis B, C serology, tumor markers and evidence of metastatic diseases were all negative. A computerized tomography examination was also inconclusive about its nature. Due to the patient's refusal of a liver biopsy, only oral antibiotics were medicated at the outpatient department. Unexpectedly, the follow-up computerized tomography, taken 4 weeks later, demonstrated that the liver mass was nearly absent, while a protruding painful lesion developed over the right chest wall. Under sono-guided aspiration, the chest wall mass was proved to be a pyogenic abscess. The Gram stain revealed gram-negative bacilli and the bacterial culture yielded K. pneumoniae. Under the impression of K. pneumoniae liver abscess with chest wall septic metastasis, after performing percutaneous drainage of the chest wall abscess, the patient was only given parenteral antibiotics for treatment. Both the liver and the chest wall abscesses were at last completely eradicated.
The prognostic factors of 21 patients with pyogenic liver abscess were analyzed. It was stated that survival is unfavourably influenced by hyperbilirubinaemia, the mixed bacterial population, the associated diseases as well as the tumorous process. As a result of portal antibiotic perfusion, there was no difference in the mortality rates of multiple and solitary liver abscesses. Based on the analysis of the prognostic factors, the surgical tactics is developed, i.e. a need for surgical exposure is supported, which imposes three tasks: exposure of the abscess/es, management of the primary process inducing the abscess and introduction of a cannula for portal antibiotic perfusion. Besides some criteria, although the author do not have experience in this field, they suggest the use of percutaneous drainage controlled by echography or CT, basically because of the lower mortality rate.
Tuberculous liver abscess has been reported in only fourteen patients in Japan and in twenty-nine patients outside Japan. Only nine of the non-Japanese patients and none of the Japanese patients have been treated for this condition without laparotomy. We report a patient who developed tuberculous liver abscess during treatment of tuberculous peritonitis. Diagnosis was made by ultrasound-guided aspiration biopsy, and the patient was treated with percutaneous drainage and transcatheter infusion of antituberculous agents. Direct infusion of antituberculous agents has more direct effects in the treatment of an abscess than systemic chemotherapy alone. Therefore, if a percutaneous catheter can be safely placed, the use of transcatheter infusion of antituberculous agents should be considered.
A rare case of a primary tuberculous liver abscess with bronchobiliary and gastrobiliary fistula formation is presented herein, emphasizing the difficulty in establishing its diagnosis. The clinical course was complicated and a wide range of antibiotics administered repeatedly, based on the initial diagnosis of a liver abscess, until the final diagnosis of a tuberculous liver abscess was established by histopathological reinvestigation of the resected liver specimen. Thereafter, antituberculous chemotherapy proved extremely effective for the alleviation of symptoms, reduction of the abscess and closure of the fistulae.