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Imaging and image-guided intervention have revolutionized management of hepatic inflammatory diseases. Pyogenic abscess is preferentially treated percutaneously. Radiologic techniques are crucial for the diagnosis of amebic liver abscess and infectious conditions of the liver in immunocompromised patients.
Imaging and imaging guided intervention have revolutionized the management of hepatic inflammatory diseases. Pyogenic abscess is preferentially treated percutaneously. Radiologic techniques are crucial for the diagnosis of amebic liver abscess and infectious conditions of the liver in immunocompromised patients.
Fusobacterium necrophorum is considered to be a member of the normal rumen flora and is the primary etiologic agent of bovine liver abscesses. Of the three biotypes of F. necrophorum, A, B, and C, only biotypes A and B have been implicated in the disease. Type B is the predominant biotype isolated from ruminal lesions and type A is the predominate biotype isolated from liver abscesses. Type A is usually found in pure culture in the liver abscesses; whereas, type B is usually found in mixed culture with either type A or with other bacterial species. Corynebacterium pyogenes, Streptococcus spp., Staphylococcus spp., and Bacteroides spp. are the most prevalent bacteria recovered from mixed cultures. Corynebacterium pyogenes is the most common species isolated and can cause disease synergistically with type B isolates.
A survey in Japan showed that of 2036 slaughtered cattle 58(3%) had abscesses in sites other than the liver. In 21 of the affected animals the lesions were pulmonary and in 32 abdominal (excluding hepatic); in five animals the lesions were found elsewhere (muscle 2, skin 2, bone 1). Nineteen (33%) of the 58 cattle also had abscesses in the liver. Obligate anaerobes alone were isolated from 17(29%) of the affected animals (Fusobacterium necrophorum 14, Bacteroides spp. 2, Peptostreptococcus anaerobius 1). A mixture of obligate anaerobes and aerobes or facultative anaerobes was isolated from 31 affected cattle: of these animals 21 yielded large and five small numbers of F. necrophorum; three yield fusobacteria other than F. necrophorum; and two yielded Propionibacterium acnes. The remaining 10 affected animals yielded only aerobes or facultative anaerobes. The numbers of viable obligate anaerobes in pus specimens were in the range 10(3)-10(9)/ml.
Arcanobacterium pyogenes, a commensal on the mucous membranes of many economically important animal species, is also a pathogen, causing abscesses of the skin, joints, and visceral organs as well as mastitis and abortion. In food animals, A. pyogenes is exposed to antimicrobial agents used for growth promotion, prophylaxis, and therapy, notably tylosin, a macrolide antibiotic used extensively for the prevention of liver abscessation in feedlot cattle in the United States. Of 48 A. pyogenes isolates, 11 (22.9%) exhibited inducible or constitutive resistance to tylosin (MIC of > or = 128 microg/ml). These isolates also exhibited resistance to other macrolide and lincosamide antibiotics, suggesting a macrolide-lincosamide resistance phenotype. Of the 11 resistant isolates, genomic DNA from nine hybridized to an erm(X)-specific probe. Cloning and nucleotide sequencing of the A. pyogenes erm(X) gene indicated that it was >95% similar to erm(X) genes from Corynebacterium and Propionibacterium spp. Eight of the erm(X)-containing A. pyogenes isolates exhibited inducible tylosin resistance, which was consistent with the presence of a putative leader peptide upstream of the erm(X) open reading frame. For at least one A. pyogenes isolate, 98-4277-2, erm(X) was present on a plasmid, pAP2, and was associated with the insertion sequence IS6100. pAP2 also carried genes encoding the repressor-regulated tetracycline efflux system determinant Tet 33. The repA gene from pAP2 was nonfunctional in Escherichia coli and at least one A. pyogenes isolate, suggesting that there may be host-encoded factors required for replication of this plasmid.
The medical records of 222 patients with liver abscess at Siriraj Hospital from 1978 to 1985 were analysed. Amoebic abscess was three times more prevalent than pyogenic abscess. In both groups middle aged males were affected more often than others. The main clinical manifestations were fever, right upper quadrant pain and hepatomegaly. History of colitis in the past, marked leukocytosis, elevation of alkaline phosphatase and a single abscess confined to the right lobe were suggestive of amoebic liver abscess. The presence of concurrent abdominal infection, marked anemia and jaundice were associated with pyogenic abscess. Patients with pyogenic abscess developed complications more often and the case fatality rate was greater than patients with amoebic abscess. Most of the patients were successfully treated with a combination of antimicrobials and drainage.
Seven children with hepatic and one with splenic abscess were evaluated using at least two of the following imaging modalities: ultrasound, radionuclide liver-spleen scan, computed tomography (CT) and angiography. Seven children had pyogenic, and one mixed pyogenic-amebic abscess. In all cases ultrasound demonstrated the lesions, which in 6/7 of hepatic abscesses were located only to the right liver lobe. 99mTc -sulphur colloid liver-spleen scans were positive in 4/4 cases while 67Ga failed to demonstrate 2/2 lesions. CT gave additional information in regard to etiology of lesions observed at ultrasound examination. Angiography performed in four cases showed vessel displacement by poorly vascularized mass lesions and arterioportal shunting in one but, overall, did not contribute to patient management. In clinically suggested hepatic-splenic abscesses, ultrasound together with CT will provide the diagnostic information needed for treatment. Follow-up studies should be performed by ultrasound.
During a 6 year period, 18 liver abscesses in 12 patients were identified by computerized tomography. Five patients had presumed hematogenous seeding. Five patients previously had bilioenteric anastomoses, stents, or both to relieve obstructive jaundice. Four patients with abscesses had recent abdominal operations. Diagnosis was established by guided needle aspiration and treatment was provided by percutaneous catheter drainage. Organism-specific antibiotics were administered to all patients. Patients were evaluated for recurrence by serial computerized tomographic studies and were clinically followed up for a minimum of 15 months. Ten of 12 patients (83 percent) and 16 of 18 abscesses (89 percent) were successfully treated by percutaneous catheter drainage. Two failures required operative intervention. In summary, the low morbidity and high success rate in treating hepatic abscesses by percutaneous drainage suggests that this therapy be tried before operative intervention is considered.
Serum alpha-fetoprotein (AFP) concentrations were estimated postoperatively at weekly intervals with the radioimmunoassay in eight adult patients. Seven patients underwent partial hepatectomies of up to 80% of the liver. Surgical drainage was carried out in one individual who had a huge pyogenic abscess in the right hepatic lobe. Despite evidence of clinical and biochemical recovery associated with normal liver regeneration, none of the sera were positive for AFP during the period 4-12 weeks after operation. This study does not support the hypothesis that the elevation of serum AFP in benign liver diseases reflects the extent of liver regeneration.
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Liver abscess is a quite rare complication in Crohn's disease. Early diagnosis and differentiation of pyogenic abscess from amoebic abscess are as important as the choosing of proper treatment in the management of liver abscess. Herein, 28-year-old man with Crohn's disease developing liver abscess is presented. He was treated with surgical drainage.
Twenty-two cases of abscess of the liver are reported. Eighteen were due to pyogenic organisms and four to amebas. The diagnosis was established based on clinical and laboratory evaluations and, above all, on ultrasonography with aspiration of the lesion. The causative organism was recovered from the aspirate in 33.3% of cases. Seventeen patients were treated by percutaneous aspiration. Two patients required insertion of a drain because of a biliary fistula. The success rate of percutaneous aspiration with or without drainage was 88.2% in our series. The two patients who had surgery had loculated abscesses with thick pus. In conclusion, the diagnosis and treatment of hepatic abscesses have benefited from advances in imaging techniques; in particular, aspiration or drainage can be performed simply under ultrasonographic guidance.
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Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.
Between March 1986 and March 1989, 20 children were diagnosed as having liver abscesses at the Pediatric Department of the Central Hospital in Valencia. 10 were amebic and 10 pyogenic abscesses. 85% occurred in children and 15% in infants. 15 of them (75%) were located in the right lobe, 80% of amebic abscesses had positive serological tests. An etiologic agent was found in 50% of the pyogenic abscesses (3: E. coli, 2: S. Aureus). 80 to 90% of patients presented abnormal prothrombin time. Sedimentation rate was very high in both groups, even at the discharge time. Hepatomegaly, fever, anemia and abdominal pain were the main clinical features. The macroscopic aspect of the aspirate was not helpful in the diagnosis. 60% of amebic liver abscesses needed only medical treatment but 80% of pyogenic abscesses deserved medical treatment and needle aspiration.
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Arcanobacterium pyogenes is a commensal and an opportunistic pathogen of economically important livestock, causing diseases as diverse as mastitis, liver abscessation and pneumonia. This organism possesses a number of virulence factors that contribute to its pathogenic potential. A. pyogenes expresses a cholesterol-dependent cytolysin, pyolysin, which is a haemolysin and is cytolytic for immune cells, including macrophages. Expression of pyolysin is required for virulence and this molecule is the most promising vaccine candidate identified to date. A. pyogenes also possesses a number of adherence mechanisms, including two neuraminidases, the action of which are required for full adhesion to epithelial cells, and several extracellular matrix-binding proteins, including a collagen-binding protein, which may be required for adhesion to collagen-rich tissue. A. pyogenes also expresses fimbriae, which are similar to the type 2 fimbriae of Actinomyces naeslundii, and forms biofilms. However, the role of these factors in the pathogenesis of A. pyogenes infections remains to be elucidated. A. pyogenes also invades and survives within epithelial cells and can survive within J774A.1 macrophages for up to 72 h, suggesting an important role for A. pyogenes interaction with host cells during pathogenesis. The two component regulatory system, PloSR, up-regulates pyolysin expression and biofilm formation but down-regulates expression of proteases, suggesting that it may act as a global regulator of A. pyogenes virulence. A. pyogenes is a versatile pathogen, with an arsenal of virulence determinants. However, most aspects of the pathogenesis of infection caused by this important opportunistic pathogen remain poorly characterized.
Arcanobacterium pyogenes, a common inhabitant of the mucosal surfaces of livestock, is also a pathogen associated with a variety of infections. In livestock, A. pyogenes is exposed to antimicrobial agents used for prophylaxis and therapy, notably tylosin, a macrolide used extensively for the prevention of liver abscessation in feedlot cattle in the United States. Many, but not all, tylosin-resistant A. pyogenes isolates carry erm(X), suggesting the presence of other determinants of tylosin resistance. Oligonucleotide primers designed for conserved regions of erm(B), erm(C), and erm(T) were used to amplify a 404-bp fragment from a tylosin-resistant A. pyogenes isolate, OX-7. DNA sequencing revealed that the PCR product was 100% identical to erm(B) genes, and the erm(B) gene region was cloned in Escherichia coli. The A. pyogenes Erm B determinant had the most DNA identity with an Erm B determinant carried by the Clostridium perfringens plasmid pIP402. However, the A. pyogenes determinant lacked direct repeat DR1 and contained a deletion in DR2. Flanking the A. pyogenes erm(B) gene were partial and entire genes similar to those found on the Enterococcus faecalis multiresistance plasmid pRE25. This novel architecture suggests that the erm(B) element may have arisen by recombination of two distinct genetic elements. Ten of 32 tylosin-resistant isolates carried erm(B), as determined by DNA hybridization, and all 10 isolates carried a similar element. Insertion of the element was site specific, as PCR and Southern blotting analysis revealed that the erm(B) element was inserted into orfY, a gene of unknown function. However, in three strains, this insertion resulted in a partial duplication of orfY.