An Unrecognized Etiology for Pyogenic Hepatic Abscesses in Normal Hosts: Dental Disease

Cryptogenic pyogenic hepatic abscesses are a diagnosis of exclusion. We have identified two patients with severe dental disease at the time of the diagnosis of their liver abscess. In both cases, oral flora was cultured from the abscess. Unlike a previous report, both patients were immunocompetent. When compared with a group of patients with liver abscesses and diverticulitis, two differences were found. In contrast to the single abscesses seen in 10 of 10 patients with diverticulitis, the patients with dental disease had multiple abscesses (p < 0.02). In addition, Fusobacterium nucleatum was cultured from both dental disease associated abscesses but only one of the diverticulitis associated liver abscesses (p < 0.05). If a liver abscess is thought to be cryptogenic, a thorough dental exam is recommended.     

Pyogenic liver abscess related to dental disease in an immunocompetent host

A 59-year-old man with poor oral hygiene presented to our hospital because of fever and chills. Abdominal ultrasonography and enhanced computed tomography (CT) revealed a liver abscess. The patient had no history of immunodeficiency and we confirmed the patient had no immunologic abnormalities. Blood culture revealed Fusobacterium nucleatum, a bacterium commonly found in the oral cavity. Even if a patient is immunocompetent, poor oral hygiene might be an independent risk factor for a pyogenic liver abscess. Professional mechanical tooth cleaning (PMTC) and appropriate self-care are recommended as a prophylaxis against not only dental, but also systemic diseases.     

Gas-containing hepatic abscess from an unusual etiology

Pyogenic hepatic abscesses used to be caused by an abdominal infection. Cholangitis due to stones is the commonest cause, followed by diverticulitis or appendicitis. Most patients presenting with pyogenic liver abscesses have a polymicrobial infection usually with Gram negative aerobic and anaerobic organisms. Escherichia coli or Klebsiella pneumoniae are frequently implicated but they do not usually produce gas into the abscesses. We comment a case of a gas-containing liver abscess after an acute pancreatitis without any risk factor associated.     

An experimental model for pyogenic liver abscess

We have developed a reproducible small-animal model for pyogenic liver abscess, suitable for investigating diagnostic and therapeutic modalities. Male New Zealand white rabbits weighing 2-3 kg were anaesthetized and the liver exposed. Gentle pressure was applied with forceps to the right hepatic lobe. A suspension of 10(5) colony forming units (cfu) Escherichia coli plus Fusobacterium necrophorum (10(6) cfu) plus Bacteroides fragilis (10(6) cfu) was immediately injected into a mesenteric vein. Two weeks later a palpable mass (mean diameter 4 cm) had developed. Thick pus could be aspirated percutaneously. Necropsy revealed a single, but often multiloculated, abscess at the site of the previous trauma. Injection of E. coli alone did not produce any abscesses and B. fragilis alone only small abscesses, with low and variable frequency. Inoculation with F. necrophorum alone produced large abscesses, and a dose-response relationship was established. This is a simple and reliable small-animal model useful in studies of imaging techniques, antibiotic regimens and invasive treatments for pyogenic liver abscess.     

Pyogenic and amebic liver abscesses

Pyogenic and amebic liver abscesses are the two most common hepatic abscesses. Amebic abscesses are more common in areas where Entamoeba histolytica is endemic, whereas pyogenic abscesses are more common in developed countries. Pyogenic abscess severity is dependent on the bacterial source and the underlying condition of the patient. Amebic liver abscess is more prevalent in individuals with suppressed cell-mediated immunity, men, and younger people. The right lobe of the liver is the most likely site of infection in both types of hepatic abscess. Patients usually present with a combination of fever, right-upper-quadrant abdominal pain, and hepatomegaly. Jaundice is more common in the pyogenic abscess. The diagnosis is often delayed and is usually made through a combination of radiologic imaging and microbiologic, serologic, and percutaneous techniques. Treatment involves antibiotics along with percutaneous drainage or surgery.     

A case of Salmonella liver abscess]

Liver abscess can be caused by bacterial, parasitic, or fungal infection. Amebic abscesses are more common, but pyogenic abscesses account for three quarters of hepatic abscess in developed countries. Most common pathogens of the pyogenic liver abscess are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci. However, liver abscess caused by Salmonella species has rarely been reported. We experienced a case of Salmonella liver abscess which improved after antibiotic therapy and percutaneous drainage. The patient was 52 years-old man who had an episode of intermittent fever, chills and epigastric pain for 2 weeks. He was diagnosed as liver cirrhosis eight years ago and diabetes three years ago. Salmonella group D, non-typhi was cultured from blood and pus from the liver respectively at the same time. With percutaneous drainage and susceptible antibiotic therapy, liver abscess decreased in size with improvements in fever and abdominal pain.     

Crohn's disease presenting as pyogenic liver abscess with review of previous case reports

A 40-yr-old male doctor from India presented with pyogenic liver abscesses as the first manifestation of Crohn's disease. The Crohn's disease itself was limited to the appendix and the adjacent cecum and could be diagnosed only 6 months after the presentation with liver abscess. This single case highlights three unusual features of Crohn's disease, and stresses the importance of meticulous search for a cause for pyogenic liver abscess when it occurs in an otherwise healthy adult.     

Hepatic Abscess Secondary to Stomach Perforation by a Fish Bone: a Rare Cause of Hepatic Abscess

Gastrointestinal foreign bodies are commonly encountered in clinical practice. However, although perforation of the gastrointestinal tract by a foreign body is not unusual, the formation of a hepatic abscess as a result of the migration of a foreign body is extremely rare. Patients usually present with atypical symptoms, and the treatment of such pyogenic liver abscesses presents a challenge. Here we report a case of hepatic abscess secondary to stomach perforation by a fish bone.     

Pyogenic Liver Abscess

Opinion statement Pyogenic liver abscess is an important and often life-threatening disorder. It is commonly caused by underlying disease of the biliary system, but more frequently, no predisposing disorder can be identified. Its diagnosis requires a high index of suspicion and imaging of the liver. The optimal treatment of pyogenic liver abscess is percutaneous drainage and intravenous broad-spectrum antibiotics with activity against enteric aerobic and anaerobic bacteria. Blood and abscess cultures should be obtained and amebic liver abscess carefully eliminated when the diagnosis is in doubt. Surgical drainage, preferably laparoscopic, is reserved for patients with complicated abscesses or after failure of response to initial medical therapy. Possible primary predisposing conditions to pyogenic liver abscess, such as biliary tract disorders, should be sought and managed accordingly. Intravenous antibiotics should be administered for a period of 2 weeks, followed by a more prolonged course of oral antibiotics. The choice and duration of antibiotic therapy, and the need for further intervention are determined by microbiologic data, the patient’s clinical response, and repeated imaging studies.     

Hepatobronchial fistula with percutaneous pyogenic abscess drainage of the liver

Percutaneous abscess drainage has been successfully used in the treatment of hepatic abscesses. We present a case of a posttraumatic pyogenic liver abscess treated by CT-guided percutaneous catheter drainage with an unusual complication of a hepatobronchial fistula. Patient management and the subtle roentgenographic features of this case are presented. Early signs of hepatobronchial fistula including paroxysms of coughing and a peculiar metallic taste during the performance of an abscessogram are reported.     

Liver abscess caused by periodontal bacterial infection with Fusobacterium necrophorum

Liver abscess is recognized as a life‐threatening disease. However, even in recent years, approximately 50% of liver abscess cases are considered to be cryptogenic. Here, we report a case of liver abscess associated with periodontal bacterial infection by Fusobacterium necrophorum, which is commonly found in the oropharyngeal flora. A 36‐year‐old man presented with fever and contrast‐enhanced abdominal computed tomography revealed multiple liver abscesses. F.necrophorum was isolated from oral smears, liver aspirates and blood samples. Liver abscesses caused by periodontal bacterial infection are rare, however, the incidence is expected to increase in the future, as periodontitis is extremely common and is on the rise as one of the most common chronic infections in the world. A systemic survey including periodontitis may be required for the exact diagnosis of the source of infection.     

Linezolid in the treatment of brain abscess due to Peptostreptococcus

Brain abscesses can be caused by bacteria, fungi, and parasites. Among bacteria, anaerobic organisms include the Bacteroides species group, Fusobacterium, Peptostreptococcus, and Propionibacterium. In these cases, a 4-week course of parenteral penicillin/cefalosporin and metronidazole is the standard of treatment. We describe a case of brain abscess secondary to anaerobic infection with Peptostreptococcus, which was successfully treated with parenteral and oral linezolid after failure of standard therapy.     

Pyogenic liver abscess: Warning indicator of silent colonic cancer

PURPOSE: Carcinoma of the colon, manifested clinically as an enterococcal hepatic abscess, in the absence of liver metastases, is very uncommon. However, having treated a patient with such a condition, we would like to draw the attention of surgeons to this possibility. Most reports describe secondary infections of hepatic metastases only in patients with a known malignancy. However, increased awareness of colonic cancer as an underlying cause of pyogenic liver abscesses will afford earlier diagnosis and treatment. METHODS: The case was analyzed for history, presentation, laboratory data, radiologic studies, and bacteriology. RESULTS: A 66-year-old woman presented with abdominal pain, fever, and chills. Imaging scans revealed a solitary liver abscess, which was successfully treated with percutaneous drainage and broad-spectrum intravenous antibiotics. Pus cultures grew Streptococcus faecalis.A search for the underlying cause led to the discovery of an adenocarcinoma of the sigmoid colon. CONCLUSIONS: An aggressive search for the underlying cause of pyogenic liver abscesses should be an integral part of the definitive treatment of this disease. After prevailing etiologies have been excluded, silent colonic cancer should be considered.     

CASE REPORT: Spontaneous Gas-Forming Liver Abscess Caused by Salmonella Within Hepatocellular Carcinoma: A Case Report and Review of the Literature

In conclusion, pyogenic liver abscess in hepatocellular carcinoma is unusual. Most of the reported cases occurred after a treatment such as transcatheter arterial embolization or percutaneous ultrasound-guided ethanol injection. Salomonella very rarely causes pyogenic liver abscesses. Only 14 cases have been reported in the English literature since 1911. Salmonella liver abscess occurring within a primary neoplasm is even rarer. There were only two such cases described in patients with hepatocellular carcinoma before. The present case is the third one, but it may be the first case of obvious spontaneous gas-forming liver abscess caused by Salmonella within hepatocellular carcinoma.     

Pyogenic abscesses and parasitic diseases

Parasitic diseases which during their course in the host switch the immune system from a T helper 1 to a T helper 2 response may be detrimental to the host, contributing to granuloma formation, eosinophilia, hyper-IgE, and increased susceptibility to bacterial and fungal infections. Patients and animals with acute schistosomiasis and hyper-IgE in their serum develop pyogenic liver abscess in the presence of bacteremia caused by Staphylococcus aureus. The Salmonella-S. mansoni association has also been well documented. The association of tropical pyomyositis (pyogenic muscle abscess) and pyogenic liver abscess with Toxocara infection has recently been described in the same context. In tropical countries that may be an interesting explanation for the great morbidity of bacterial diseases. If the association of parasitic infections and pyogenic abscesses and/or fungal diseases are confirmed, there will be a strong case in favor of universal treatment for parasitic diseases to prevent or decrease the morbidity of superinfection with bacteria and fungi.     

Endoscopic transpapillary abscess drainage for a patient with giant pyogenic liver abscess

The primary modalities for management of liver abscesses are usually antibiotics and percutaneous drainage. However, in patients with ascites or bleeding tendency, the percutaneous puncture of liver abscesses may be unsuitable. We applied a new approach, nasobiliary tube drainage, for a giant pyogenic liver abscess following diagnostic endoscopic retrograde cholangiopancreatography. Pyogenic liver abscess is often biliary in origin, and this new approach includes assessment of biliary abnormality for the management of the abscess, enabling treatment of parients in whom puncture of the abscess is considered dangerous because of massive ascites around the liver. We propose that this procedure is useful in the management of a subgroup of patients with pyogenic liver abscess. To our knowledge, no previous reports of endoscopic transpapillary abscess drainage in pyogenic liver abscess are available.     

Pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma

Background

Pyogenic liver abscess and hepatocellular carcinoma are common in Taiwan. We investigated the frequency of, risk factors for, and prognosis of pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma over a 12-year period in Taiwan.

Methods

We extracted 32,454 patients with pyogenic liver abscess from a nationwide health registry in Taiwan during the period 1997-2008. The frequency of and risk factors for pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma were determined. The prognosis of these patients was compared with patients with hepatocellular carcinoma but without liver abscess.

Results

A total of 698 (2.15%) patients presented with liver abscess as the initial manifestation of underlying hepatocellular carcinoma during the 12-year period. Liver cirrhosis, hepatitis B virus infection, hepatitis C virus infection, and age ≥65 years were independent risk factors for liver abscess as the initial manifestation of underlying hepatocellular carcinoma. Furthermore, these patients had a lower 2-year survival rate than patients with hepatocellular carcinoma but without liver abscess (30% vs 37%; P = .004).

Conclusions

The prognosis of patients who presented with pyogenic liver abscess as the initial manifestation of underlying hepatocellular carcinoma was poor. Physicians should not ignore the possibility of underlying hepatocellular carcinoma in patients with risk factors for the disease in regions with a high prevalence of both pyogenic liver abscess and hepatocellular carcinoma.     

Tuberculous hepatic abscess appearing after liver transplantation in a patient with human immunodeficiency virus and hepatitis B and C virus co‐infection

M. Rodríguez‐Framil, A. Antela, A. Prieto, E. Otero, E. Molina, E. Varo. Tuberculous hepatic abscess appearing after liver transplantation in a patient with human immunodeficiency virus and hepatitis B and C virus co‐infection.
Transpl Infect Dis 2011: 13: 515–519. All rights reserved Abstract: Tuberculosis infection occurs relatively frequently in solid organ transplant recipients, although the occurrence of tuberculous hepatic abscesses is uncommon. Anti‐tuberculous therapy has several concerns in transplant recipients, including an increased risk of cellular rejection and potential hepatotoxicity. We present the case of a human immunodeficiency virus‐infected liver transplant patient who developed multiple tuberculous liver abscesses. Treatment with isoniazid, ethambutol, pyrazinamide, and moxifloxacin was efficacious, well tolerated, and safe.     

Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases

Distinguishing amoebic from pyogenic liver abscesses is crucial because their treatments and prognoses differ. We retrospectively reviewed the medical records of 577 adults with liver abscess in order to identify clinical, laboratory, and radiographic factors useful in differentiating these microbial aetiologies. Presumptive diagnoses of amoebic (n = 471; 82%) vs. pyogenic (n = 106; 18%) abscess were based upon amoebic serology, microbiological culture results, and response to therapy. Patients with amoebic abscess were more likely to be young males with a tender, solitary, right lobe abscess (P = 0.012). Univariate analysis found patients with pyogenic abscess more likely to be over 50 years old, with a history of diabetes and jaundice, with pulmonary findings, multiple abscesses, amoebic serology titres <1:256 IU, and lower levels of serum albumin (P < 0.04). Multivariate logistic regression analysis confirmed that age >50 years, pulmonary findings on examination, multiple abscesses, and amebic serology titres <1:256 IU were predictive of pyogenic infection. Several clinical and laboratory parameters can aid in the differentiation of amebic and pyogenic liver abscess. In our setting, amebic abscess is more prevalent and, in most circumstances, can be identified and managed without percutaneous aspiration.     

Experimental anaerobic liver abscess: observations on treatment

Various treatment modalities for solitary anaerobic liver abscesses were evaluated in a recently-described rabbit model. In the first phase of the experiment, 35 rabbits with liver abscesses induced with Bacteroides fragilis and Fusobacterium necrophorum were randomized into four groups: surgical drainage alone, drainage plus clindamycin 150 mg IM 8-hourly, clindamycin alone, and untreated controls. Serum clindamycin concentrations in rabbits were similar to those achieved in humans. The survival of rabbits receiving antibiotic chemotherapy alone was significantly better than controls, whereas the survival of those having surgical drainage with or without chemotherapy was not. However, successful surgical drainage was followed by weight gain in surviving rabbits. In the second phase of the experiment 18 rabbits with abscesses were randomized into the same groups. Aspirates of pus from all rabbits receiving clindamycin were sterile by day 7 of treatment, but high bacterial counts were still present in the abscess cavities of control rabbits and of those undergoing drainage alone. These findings illustrate the application of a new model for pyogenic liver abscess in laboratory investigation. Their relevance to management of human pyogenic liver abscesses remains to be assessed.