Sonography in recurrent oriental pyogenic cholangitis.
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[Method for draining purulent parts of the liver].
Percutaneous draining of purulent cavities in the liver is an effective method for the treatment of pyogenic diseases of the organ. The traditional method, however, has some shortcomings which often lead to serious complications (intraperitoneal hemorrhage, escape of bile, breaking away of the catheter, hypostatic pneumonia, etc). The work deals with the results of treatment of 32 patients with purulent diseases of the liver. Abscess of the liver was found in 8 patients, subdiaphragmatic abscess in 6, suppurating hydatid cyst in 8, nonparasitic cyst in 5 patients. In 18 patients the traditional method of draining was applied, in 14 patients draining was conducted by a method suggested by the authors. Complications occurred in 11 patients treated by the traditional method, whereas in patients treated by the improved method the postoperative course was uneventful, no complications were encountered. Thus, the improved method for draining purulent cavities in the liver reduces significantly the incidence of postoperative complications and improves the results of treatment.
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Nonspecific pyogenic spondylodiscitis: clinical manifestations, surgical treatment, and outcome in 24 patients.
OBJECT: Pyogenic vertebral osteomyelitis is of special interest to neurosurgeons because it often results in acute neurological deterioration and requires a combination of adequate surgical and conservative treatment. The aim of the current study was to evaluate the strategy of a primary surgical approach to this disease. METHODS: A group of 24 patients with the clinical and radiological signs of acute pyogenic spondylodiscitis was prospectively followed from 1998 to 2004. Of these, 20 had underlying diseases such as diabetes mellitus, chronic alcoholism, and liver cirrhosis. The main causative organism was Staphylococcus aureus. Most infections were localized in the thoracic or lumbar spine (10 cases each); 15 infections were associated with epidural abscesses. Because of a delay in diagnosis, 13 patients presented with neurological deficits on admission. Patients with a complete or rapidly progressing neurological deficit underwent immediate surgery. In patients with minor or no deficits or in a stable neurological condition, surgery was delayed for 3 to 5 days. This group was treated with immobilization and intravenous antibiotic drugs before surgery. Surgical procedures included ventral, dorsal, and combined approaches in one- or two-stage operations. Antibiotic treatment included the use of broad-spectrum antibiotic drugs delivered intravenously for at least 10 days, followed by orally administered antibiotics for 3 months. Twenty patients were independent on follow-up review, 15 with no or minor handicaps. Severe septicemia and multiorgan failure developed in two patients, and these two died of their disease. Major complications were mainly due to long-term antibiotic therapy. CONCLUSIONS: Surgical treatment is the modality of choice in patients with acute spinal osteomyelitis. It is especially indicated in patients with progressive or severe neurological deficits and spinal deformity. In experienced hands, surgery is safe and offers the advantages of spinal cord decompression, immediate mobilization, and correction of spinal deformity. The decision whether an anterior or posterior approach should be used must be made on an individual basis.
Adult↗
Some new aspects of the pathology, pathogenesis, and aetiology of disseminated lung lesions in slaughter pigs.
From 40 pigs rejected for human consumption at slaughter due to an apparent presence of pyemic lung lesions (defined as disseminated processes containing pus and/or necrotic material), the lungs, spleen, liver, and kidneys were subjected to an extended macroscopic examination. Several lung lesions were sampled from each animal for histological and bacteriological examination. Samples from the kidneys and spleens were also subjected to bacteriological examination. At gross level, four groups of lung lesions were identified: 1) disseminated foci with contents of pus and/or necrotic material (n=26); 2) disseminated or multifocally located ecchymoses with a central area of fibroplasia (n=9); 3) non-pneumonic lesions, i.e., disseminated areas of atelectasis (n=1) or haemorrhagic areas developing due to the process of slaughter (n=1); and 4) suppurative lesions without a disseminated distribution pattern (n=3). Histologically, the disseminated suppurative/necrotic foci were identified as: A) abscesses (n=10); B) necrotic lesions (n=6); and C) ectatic or ectatic-like bronchioles with contents of pus and necrotic material (n=10). The macroscopic observation of disseminated centres of fibroplasia with peripheral ecchymoses (n=9) was confirmed histopathologically. The livers of five pigs contained multiple areas of chronic interstitial fibrosis related to migration of Ascaris suum larvae ("milk spotted liver"). Such hepatic lesions were significantly (p<0.01) related to the simultaneous occurrence of disseminated pulmonary ecchymoses with a central area of fibroplasia. Generally, all lung lesions of each individual animal contained identical monocultures of bacteria following this pattern: Staphylococcus aureus (abscesses); Actinomyces hyovaginalis (necroses); S. aureus, A. hyovaginalis, and Arcanobacterium pyogenes (ectatic and ectatic-like bronchioles). Areas with fibrosis were sterile or contained bacteria considered to be a result of contamination. Apart from one kidney, from which S. aureus was cultured, all other organs were sterile. It is concluded that difficulties exist in differentiating pulmonary pyemic lesions from non-pyemic lesions at the gross level. Thus, it was not possible to distinguish between abscesses/necroses and ectatic bronchioles, the pathogenesis of the latter being uncertain. However, the chronic non-pyemic lesions related to the migration of A. suum larvae should be identified by the absence of pus/necrosis. S. aureus was predominantly isolated from abscesses, whereas, and most surprisingly, A. hyovaginalis was the dominant bacterium isolated from the pulmonary necroses.
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Ga-67 imaging in primary and secondary psoas abscess.
Primary and secondary psoas abscesses are uncommon and frequently misdiagnosed. Two cases of pyogenic psoas abscess are presented to illustrate the usefulness of Ga-67 scintigraphy in determining the presence and the extent of the infectious process.
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Papillon-Lefèvre syndrome with pyogenic hepatic abscess: a rare association.
Papillon-Lefèvre syndrome in a 14-year-old boy presenting with palmoplantar keratoderma, periodontosis, recurrent pyogenic infections of the skin, and hepatic abscesses is reported for its rarity and unusual manifestations. The patient showed a dramatic response to acitretin therapy.
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Fusobacterium necrophorum hemolysin in bovine hepatic abscess.
An immunofluorescence study was made on bovine hepatic abscess containing Fusobacterium necrophorum predominantly. The abscess section stained with anti F. necrophorum hemolysin serum demonstrated fluorescence which formed irregular and granular shapes. Actinomyces pyogenes isolates from the abscess were not stained with the serum. These findings suggest that the bacterial hemolysin contributes to the formation of the hepatic abscess during an infection with F. necrophorum.
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Pyogenic hepatic abscess.
Presented is a case of spontaneous pyogenic hepatic abscess in a previously healthy young man without associated risk factors. This disease entity has a low incidence, however, it is associated with significant morbidity and mortality if diagnosis and treatment are delayed.
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Brainstem infarcts as an early manifestation of Streptococcus anginosus meningitis.
BACKGROUND AND PURPOSE: Vasculitis and infarcts are well-established sequelae of bacterial meningitis. However, early large-vessel involvement is rare, particularly within the brainstem. There has been one previous case report of a young male who presented with pontine infarct as an early manifestation of Streptococcus milleri meningitis. We present another case of brainstem infarction associated with meningitis caused by Streptococcus anginosus. CASE DESCRIPTION: We report a 58-year-old man who developed constitutional symptoms and gait instability, followed by progressive stupor. On examination, he had a Glasgow Coma Scale of 8 with intact brainstem reflexes and no focal findings. Magnetic resonance imaging documented bilateral pontine infarcts. S. anginosus was isolated from cerebrospinal fluid. Despite proper antibiotic treatment, the patient remained comatose and care was withdrawn. Postmortem examination revealed the meningitis was predominantly localized at the base of the brain. In addition, ventriculitis, multiple abscesses, and multiple infarcts in the pons and midbrain were found. CONCLUSION: S. anginosus, which is part of the normal human flora, causes invasive pyogenic infections and is an uncommon cause of bacterial meningitis. This type of infection is mostly situated at the base of the brain and has a propensity to encase the basilar artery and its perforators, thus causing brainstem stroke early in its course.
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[Suburban amebiasis: the diagnostic aspects via computed tomography and echography and the percutaneous treatment of amebic liver abscesses].
INTRODUCTION: Liver is the most common site of extraintestinal amebiasis and hepatic abscesses are the most frequent symptom, occurring in 3-9% of patients with amebic infection. Several studies have shown that drug treatment is more efficacious when combined with percutaneous drainage of the abscess, yielding quicker recovery and a positive body response. We report our US and CT findings in 16 patients with amebic abscesses, 12 of whom lived in a temperate peripheral area north-east of Naples. All patients had a clinical-diagnostic condition that we called "suburban amebiasis". Finally we report our personal experience with the US-guided therapeutic drainage of amebic abscesses with repeated cavity washings, which is important for positive parasitology. MATERIAL AND METHODS: We retrospectively reviewed the findings of 16 patients (11 men and 5 women; age range 36-78 years; mean 52) with amebic abscesses of liver examined with US and CT. US with a 3.5 MHz transducer was the technique of choice in all patients. 94% of liver abscesses and some extraintestinal complications were easily shown with this technique. CT angiography was then performed to detail and clarify US findings. Abscesses over 4 cm in diameter were submitted to US-guided percutaneous treatment which permitted abscess drainage, the collection of material for parasitology and repeated cavity washings. RESULTS: US showed multiple liver abscesses in 12 patients, which were multiseptate and formed by multiple hypo-/hyperechoic microabscesses in 4 of them. Four non-European patients had a single abscess, which is typical of tropical endemic forms. CT showed the amebic abscesses as hypodense roundish masses with clear-cut outline most often localized in the right lobe in the 12 multiple cases. After percutaneous drainage 13/16 patients (81%) reported less pain in the right hypochondrium and had a lower temperature; their hospitalization was also shorter. DISCUSSION AND CONCLUSIONS: Combined US and CT assessment facilitated the diagnosis of amebiasis and its differentiation from pyogenic abscess and hepatoma. The combination of US-guided drainage and drug treatment provides better results than either treatment alone and quicker improvement of patient conditions, with fewer extraintestinal complications. Percutaneous drainage should be used in abscesses bigger than 4-5 cm, those with questionable clinical-laboratory findings and finally those failing to respond to drug treatment alone. Positive parasitology of abscess content is related to repeated cavity washings after percutaneous drainage, likely because peripheral layers are much richer in amebae.
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Bacteriologic and histologic studies of hepatic abscesses in cattle.
Twenty-eight abscessed livers were collected from feedlot cattle at an abattoir; specimens were obtained from 49 abscesses for bacteriologic culture and for histologic examination. Cultural procedures included techniques to enumerate and isolate facultative and obligate anaerobic bacteria. Anaerobic bacteria were isolated from all 49 abscesses, whereas facultative bacteria were isolated from only 22. Mean bacterial counts for anaerobic and facultative bacteria were 3 X 10(8) and 8 X 10(8) bacteria/g of purulent material, respectively. Fusobacterium necrophorum, the only anaerobe isolated, was detected in 100% of the abscesses. Fusobacterium necrophorum biotype A was isolated from 57% of the abscesses (in pure culture from 75%), and F necrophorum biotype B was isolated from 47% of the abscesses (from 96% with mixed infections). Corynebacterium pyogenes was the predominant facultative bacterium isolated. Histologic changes in abscesses were qualitatively similar; abscesses were pyogranulomatous, with a necrotic center surrounded by zones of inflammatory tissue. However, the severity of lesions varied, depending on the F necrophorum biotype involved. Portal triad fibrosis and bile-duct proliferation were most severe in biotype A and mixed biotype B infections and less severe in abscesses from which biotype B was isolated in pure culture.
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Intermittent hepatic artery antibiotic infusion therapy for pyogenic hepatic abscess.
PURPOSE: To study the efficacy and problems associated with intermittent hepatic artery antibiotic infusion therapy for pyogenic hepatic abscess. MATERIAL AND METHODS: The material comprised eight patients with pyogenic hepatic abscess in whom percutaneous drainage could not be performed and intravenous administration of antibiotics was ineffective. An injection catheter was introduced into the common hepatic artery. Almost the same dose of antibiotics as with intravenous administration was infused intra-arterially 2-4 times per day. RESULTS: A therapeutic effect was achieved in six of the eight cases. In these 6 cases, the mean period of intra-arterial infusion was 10.8 days, while the mean period of catheter placement was 14.7 days. Using broad spectrum antibiotics, the therapeutic effect was obtained regardless of the numbers, morphologic characteristics, and differences in location of the abscesses. No significant complications were noted except in one case of splenic infarction. CONCLUSION: Intermittent hepatic artery antibiotic infusion therapy is useful as an alternative therapeutic procedure for pyogenic hepatic abscess in which percutaneous drainage cannot be performed and intravenous administration of antibiotics is ineffective.
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Endoscopic retrograde cholangiopancreatography and endoscopic papillotomy in recurrent pyogenic cholangitis.
In recurrent pyogenic cholangitis (RPC), there is primary bacterial cholangitis resulting in the formation of strictures and stones in the intrahepatic as well as the extrahepatic bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP) is a very useful investigation in the study of RPC. The location of stones and strictures and the morphology of the bile ducts are well delineated. Moreover, cholangitis liver abscesses and biliary-enteric fistulas, which are frequently encountered in RPC, are demonstrated. ERCP can also be used to differentiate RPC from ascariasis, clonorchiasis, hepatocellular carcinoma and cholangiocarcinoma, which sometimes have quite similar clinical pictures and can be confused with RPC. ERCP should be performed in every patient with RPC in order to plan surgical treatment. Endoscopic papillotomy (EPT) is indicated in RPC patients with residual common bile duct stones or papillary stenosis, and as primary treatment in selected high-risk patients. More studies are necessary to establish additional indications for EPT.
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[A case report of toxic shock-like syndrome due to group A streptococcal infection in an alcoholic].
A 47-year-old male with a history of alcohol abuse had a sore throat on June 8, 1994. On June 13, he had swelling and pain on his right fore-arm. He had tense swelling, redness and pain on the right lower abdomen, left upper arm and left lower leg with high fever and noticed erythema and blisters on his back of the right hand on June 18, which gradually expanding to the entire fore-arm. He was admitted to the local hospital on July 2, where he was operated with excision of the skin and drainage for an abdominal subcutaneous abscess and was given three antibiotics and an intravenous immunoglobulin preparation. Although he showed transient hypotension and moderate liver dysfunction, his condition improved day by day under such treatment. He was transferred to our hospital on July 7 because of the unknown etiology. Aspirate from the abscess contained gram-positive cocci in chains, and group A streptococci were isolated. Panipenem/betamipron was used for an antibiotic during roughly two weeks and excision of the skin and drainage for abscess was performed twice. His skin lesions were continued to improve, normalizing peripheral white blood cell counts, serum levels of CRP and the liver function. On July 24, the antibiotic was changed to intravenous ampicillin and administered for 16 days and amoxicillin was given orally after that, and he was discharged on August 16. An isolate of the infecting Streptococcus pyogenes produced pyrogenic exotoxin A, B and the serotype was T-3 type.
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The behavior of virulent and avirulent staphylococci in the tissues of normal mice.
The fate of hemolytic staphylococci injected intravenousiy into albino mice was followed by determining quantitatively the numbers of living organisms present in the various tissues at different intervals of time after infection. Irrespective of the strain of staphylococcus used, most of the organisms disappeared rapidly from the blood, liver, spleen, and kidneys. This was true even when the infective dose consisted of large numbers of virulent, coagulase-positive staphylococci, capable of producing a fatal disease in a high percentage of the infected mice. The initial rate of removal or destruction of staphylococci was particularly high in the lungs and kidneys. In all cases on the other hand, a few living staphylococci persisted in the various organs for several weeks after infection, even when the organisms were non-virulent and coagulase-negative. Although virulent as well as avirulent staphylococci were eliminated extremely rapidly and efficiently from the kidneys during the initial stage of infection, the microorganisms soon began to multiply in this organ, causing abscesses first detected in the cortex. Death of the animals infected with virulent cultures appeared to be due to the destruction of renal tissue by these abscesses. The abscesses caused by the avirulent strains eventually became sterile, and healed. No convincing difference could be recognized amongst seven strains in their resistance to the bactericidal power of the mouse tissues during the initial phase of the infection. In contrast, marked quantitative differences came to light in their subsequent behavior in the kidneys. The multiplication of the coagulase-negative staphylococci in this organ soon came to an end in all animals and never proceeded far enough to result in fatal disease. The staphylococci of a weakly coagulase-positive strain multiplied somewhat more extensively in the kidneys than did the coagulase-negative, but never sufficiently to cause the death of any animal within the period of observation of 1 month. The three coagulase-positive strains tested yielded the largest bacterial population in the kidneys and caused the death of many of the infected animals. These three virulent strains differed quantitatively amongst themselves with regard to both the rapidity and extent of their multiplication in the kidneys and the lethal power of a given infective dose. Taken together, the findings indicate that the hemolytic strains of staphylococci can be arranged in a continuous spectrum according to their ability to cause disease in albino mice. Although virulence for these animals appeared to be correlated with the production of coagulase, it did not seem to depend upon the ability of this substance to interfere with the bactericidal mechanisms of the mouse organs during the early phase of the infection. Virulence manifested itself chiefly by the production in the kidneys of progressive abscesses originating from the few staphylococci which were not destroyed during the initial bactericidal reaction.
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[Pyogenic hepatic abscesses: role of ultrasonography in their diagnosis and treatment].
We present 26 cases of pyogenic hepatic abscess diagnosed by echography, 14 of which were treated by percutaneous drainage guided by ultrasound. An analysis is made of the clinical and radiological findings, as well as the differential diagnosis of focal hepatic lesions. Due to the lack of clinical specificity in many patients, we recommend fine needle biopsy directed by ultrasound to confirm the suspicion of pyogenic hepatic abscess and isolation of noncausative microorganisms. We think that the treatment of choice in these patients is percutaneous drainage guided by echography.
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Multilocular pyogenic hepatic abscess complicating ascaris lumbricoides infestation.
A 74-year-old man was admitted to our hospital with frequent right flank pain. The multiple multilocular hepatic abscesses were revealed by computed tomography. Radiographs following a barium meal showed a linear filling defect in the ileum consistent with ascariasis. One day after treatment with pyrantel pamoate, an Ascaris was passed in the stool. The pyogenic hepatic abscesses gradually healed with both antibiotics and continuous drainage. After 2 months, he was discharged. In this case, the pyogenic hepatic abscesses were thus considered to have been caused by an inflammation which spread through the portal vein.
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Pyogenic hepatic abscess in a community hospital.
Pyogenic hepatic abscesses are rare lesions and are most commonly the result of biliary tract disease. During a 3-year period at our institution, 15 patients were diagnosed with pyogenic hepatic abscess. Ten cases were related to biliary disease. Of these, five were associated with previous biliary tract operations. The remaining five were due to metastases, infection at another site, or cryptogenic causes. Most abscesses were multiple. Treatment consisted of antibiotics alone for three patients, percutaneous drainage and intravenous antibiotics for seven patients, open drainage with intravenous antibiotics for three patients, and papillotomy with intravenous antibiotics for one patient. The single untreated patient died. The other death occurred among those patients treated with intravenous antibiotics alone. Four patients initially treated by percutaneous drainage required subsequent open drainage. All of these patients had multiple abscesses. The mean length of stay in the hospital was least among the group treated by operative drainage. Our review suggests that pyogenic hepatic abscesses may be treated by several different modalities, the choice of management should be individualized, and the length of stay may be decreased by operative drainage.
Anti-Bacterial Agents↗