Liver abscess in children: an overview

Something Seems Fishy: Hepatic Abscess Due to Foreign Body Ingestion in a Pediatric Patient

Pediatric hepatic abscesses are uncommon in children. They are usually preceded by intra-abdominal infections or caused by acute or chronic biliary disease. Cases of hepatic abscesses secondary to foreign body ingestion are even rarer but are most reported in countries such as China, where ingestion of fish and chicken bones is common. We report a rare case of an adolescent patient who developed a hepatic abscess after ingestion of a fishbone foreign body. He presented to the emergency department with emesis, abdominal pain, and subjective fevers of unknown etiology. Initial imaging of the abdomen was pertinent for a heterogeneous hepatic mass with evidence of fluid collection, concerning for malignancy. Subsequent incision and drainage then confirmed fluid collection to be pus. However, his cryptogenic hepatic abscess was not responsive to broad-spectrum intravenous antibiotics. After imaging was re-reviewed and repeated, a 4.3 cm thin curvilinear hyperdensity was identified embedded in the liver parenchyma. Eventually, the patient underwent exploratory laparoscopy where a fishbone foreign body was removed. To our knowledge, this is one of the few reported pediatric cases of hepatic abscess formation caused by a foreign body ingestion. Hepatic abscesses that do not resolve with antibiotics and ultrasound-guided drainage via catheter should prompt reassessment of other uncommon etiologies, specifically migrated foreign bodies as a rare but important differential diagnosis. Compared to pyogenic hepatic abscesses, hepatic abscesses secondary to foreign bodies require expedited surgical intervention for source control; thus, timely recognition and prompt intervention are crucial to minimize morbidity and mortality.

Pyogenic liver abscess in pediatric populations in beijing (2008-2023)

BACKGROUND

Data on pyogenic liver abscess (PLA) of children in China have been limited. We aimed to summarize the clinical feather, microbiological characteristics, management, and outcome of PLA in children.

METHOD

We retrospectively reviewed PLA cases from January 2008 to June 2023 at Beijing Children's Hospital. Clinical characteristics, pathogens and management were analyzed.

RESULTS

We diagnosed 57 PLA patients in our center. The median onset age was 4.5 years and the male-to-female ratio was 1.6:1. The median diagnostic time was nine days and the median length of stay was 22 days. Twenty-eight patients (49.1%) had predisposing factors, around 71.4% of the patients had malignant hematology and primary immunodeficiency disease. Patients with underlying factors were more likely to have extrahepatic organ involvement (p = 0.024), anemia (p < 0.001), single abscess (p = 0.042), unilateral involvement (p = 0.039), and small size of the abscess (p = 0.008). Twenty-four patients (42.1%) had extrahepatic organ involvement. Pathogens were identified in 17 patients (29.8%), the most common pathogens were Klebsiella pneumoniae and Staphylococcus aureus. The positive rate of metagenomic next-generation sequencing (mNGS) was 87.5% (7/8). On multivariable analysis, the extrahepatic organ involved (p = 0.029) and hepatomegaly (p = 0.025) were two independent factors associated with poor outcomes.

CONCLUSIONS

PLA is usually seen in children with predisposing factors. Malignant hematology and primary immunodeficiency disease were the most common underlying diseases. Extrahepatic organ involvement and hepatomegaly are associated with poor prognosis. Increased use of mNGS could be beneficial for identifying pathogens.

Concomitant Occurrence of Hepatitis A and a Pyogenic Liver Abscess: A Pediatric Case

Pyogenic liver abscess (PLA) and hepatitis A are common in developing countries. As there is an overlap of clinical features, a diagnosis of dual infection can be missed. Here, we present the case of a five-year-old male who presented with abdominal pain, fever, and jaundice diagnosed as a complicated liver abscess with concurrent hepatitis A. To our knowledge, this is the first case where a PLA co-existed with hepatitis A. Simultaneous infection should be considered when a patient with liver abscess presents with jaundice, especially in areas where both diseases are endemic. Early diagnosis of both is crucial as PLA is a potentially fatal disease and co-infection with hepatitis A may worsen clinical outcomes.

Difficult to treat liver abscesses in children - Do not forget parasitic infections

Liver abscess (LA) is a significant health concern worldwide, particularly in tropical regions such as India, and is usually pyogenic or amoebic in origin. In rare cases it can be caused by parasites. We present two children with difficult-to-treat LAs, revealing underlying parasitic infections as the causative agents, implicated by eosinophilia, elevated immunoglobulin-E levels and exposure to domestic animals. In the first case, disseminated echinococcosis was diagnosed through imaging, serology and histopathology. The second case showed a relationship between LAs and Toxocara infection, evidenced by microscopic stool examination of a household cat.

Fever of Unknown Origin: A Case Report of Hepatic Phlegmon in an Immunocompetent Patient

Methicillin-resistant Staphylococcus aureus (MRSA) hepatic phlegmon is a rare cause of fever of unknown origin (FUO) in an immunocompetent patient from a high-income country (HIC). MRSA hepatic phlegmon is typically linked to protein malnutrition and chronic gastrointestinal infections in low- to middle-income countries while immunodeficiencies such as chronic granulomatous disease (CGD) are a more common cause in a HIC. Clinical manifestations of hepatic phlegmon can be vague and nonspecific making a complete FUO workup critical during evaluation. We report a case of MRSA hepatic phlegmon in an immunocompetent patient with a nonspecific history and physical exam findings. A 14-year-old male presented with an 11-day history of fever with mild bilateral upper quadrant abdominal pain. The patient also has mild upper quadrant pain with palpation. The patient was diagnosed with a hepatic phlegmon on abdominal ultrasound and computed tomography (CT) of the abdomen. He was started on antibiotics and Interventional Radiology placed drains into the phlegmon and performed vancomycin drain washes. Inflammatory markers were initially elevated and trended down with interventions. The patient did well with treatment and was back to baseline during outpatient follow-up with the Infectious Disease team. This case illustrates the importance of a complete workup in patients with FUO.

Liver Abscess as an Uncommon Complication of Laparoscopic Appendectomy: A Case Report

Pyogenic liver abscess (PLA) is an infrequently seen complication of appendicitis that once was common, but now is so rare many textbooks omit the condition entirely. In this report, we document a recent case of post-appendicitis PLA in an eight-year-old Hispanic female treated with a combination of medical and surgical management. We have detailed the course of treatment, both to raise awareness of this uncommon complication of appendicitis and to help provide a guide for other clinicians treating similar cases. While cases of pediatric PLA post-appendicitis are rare in the modern world, timely diagnosis and treatment of the lesions are paramount to patient recovery and prevention of long-term sequelae. Study of prior literature and research is likely to be of vital importance to the treatment of the condition. Multiple treatment modalities may be considered, and there is no true standard of care for pediatric populations presenting with PLA.

Neonatal pyogenic liver abscess following omphalitis: A case report

INTRODUCTION AND IMPORTANCE

Liver abscesses in neonates are rare. Omphalitis is a very rare cause. We report a case of a voluminous neonatal pyogenic liver abscess following omphalitis, successfully managed in our institution.

CASE PRESENTATION

A 21-day-old full-term female newborn was brought to our institution for progressive febrile swelling of the right hypochondrium. The parents reported umbilical suppuration. Clinical examination confirmed the presence of a mass extending from the epigastric region to the right hypochondrium in a febrile baby with no other abnormalities. Laboratory investigations revealed an elevated C-reactive protein level (64 mg/dl) and hyperleukocytosis (20,800/mm3) with neutrophil predominance and normochromic microcytic anemia (hemoglobin 8.2 g/dl). Her first abdominal ultrasound was interpreted as a cyst of the common bile duct. Triple antibiotic therapy with cephalosporin, ampicillin and gentamycin was started, but unsuccessful. Abdominal ultrasound was repeated, revealing a hepatic abscess in segment 8, with a volume of approximately 17 ml. Percutaneous echo-guided drainage was performed and antibiotic therapy was readjusted after identification of the germ (Staphylococcus aureus) with good outcome. The baby was discharged two weeks later. At one month follow-up, the baby was completely asymptomatic.

CLINICAL DISCUSSION AND CONCLUSION

As neonatal liver abscesses are unusual, they can lead to misdiagnosis. Omphalitis is a very rare cause. Treatment by percutaneous echo-guided drainage is simple and effective.

Severe congenital neutropenia and liver abscess: Surgical treatment breaks the vicious cycle

Here, we present a case with genetically confirmed SCN. The main symptom of the child was recurring fever. The combination of antibiotics combined with G-CSF injection was proved to be insufficient, and the patient developed "solid" liver abscess. After undergoing surgical anatomical hepatic lobectomy, the child's infection symptoms showed improvement. The postoperative culture of the purulent material from the liver infection lesion revealed an infection with Staphylococcus aureus. Our case raises the possibility of pathogen sources and routes of infection, clinical characteristics, and effective treatment for SCN patients with concomitant liver abscess.

Assessment of risk factors in pyogenic liver abscesses in children

Background

Pyogenic liver abscess (LA) is a significant contributor to morbidity and mortality in developing countries like India. The risk factors predisposing to the LA specifically in children are not known. Studies done in the past largely remain inconclusive and have identified only probable causes. The cause of LA in children with no coexisting illness remains unknown.

Methodology

This prospective observational study was conducted at a tertiary teaching hospital located in New Delhi, India. All children between 2 months and 12 years of age with sonographically confirmed LA presenting to the hospital were included and managed with appropriate intravenous antibiotics and relevant investigations.

Results

A total of 52 children were included. The mean age was 6 years and 4 months, and the male: female ratio was 1.4:1. Around 50% of the patients were malnourished. Fever, abdominal pain and loss of appetite were the most common symptoms. Nine patients (17%) were managed conservatively, 13 (25%) needed percutaneous needle aspiration and 30 (57.69%) required drainage using a pigtail catheter. Poor socioeconomic status and anaemia were found to be the most commonly associated risk factors. Selective immunoglobulin A (IgA) deficiency was the most common primary immunodeficiency disorder followed by T-cell defect. On multivariate analysis, it was seen that in those with clinical icterus, gamma-glutamyl transferases >350 IU/m, and those with impending rupture, the time to defervescence was significantly different (P = 0.05).

Conclusion

Poor socioeconomic status causing malnutrition emerged as a significant risk factor for LA in children. Selective IgA deficiency was the most common immunodeficiency seen in a few children. Adopting a conservative approach like aspiration and percutaneous drainage led to lower mortality and good recovery rates.

Pediatric Liver Abscess: Outcomes of Protocol-based Management and Predictors of Poor Outcome

BACKGROUND

Liver abscess (LA) is an important cause of morbidity in children, especially in tropical countries. There is a paucity of data in pediatric LA with no standard guidelines regarding the best modality of treatment and drainage. With a large influx of patients at our center and protocol-based management; we aimed to study clinic-radiologic profile, risk factors, complications and outcomes of children with liver abscess and assessed possible predictors for poor outcomes.

MATERIALS AND METHODS

This retrospective observational study was conducted from January 2019 to September 2019 at a tertiary care hospital in India. Records of all children (<12 years of age) with ultrasonographically diagnosed liver abscess were accessed for clinic-radiological and demographic profile, laboratory investigations, treatment, complications and outcomes. Patients were categorized into favorable or unfavorable groups based on predefined criteria and were compared for possible predictors of poor outcomes. Outcomes for the protocol-based management were analyzed.

RESULTS

There were 120 cases of pediatric liver abscess with a median age of 5 years at presentation. The commonest clinical features were fever (100%) and pain in the abdomen (89.16%). The majority of liver abscesses were solitary (78.4%) and in the right lobe (73.3%). Malnutrition was present in 27.5%, overcrowding for 76.5% of patients and worm infestation in 2.5% of patients. Age-related leukocytosis (P = 0.004), neutrophilia (P = 0.013), elevated Aspartate transaminase (P = 0.008), elevated alanine transaminase (P = 0.007) and hypoalbuminemia (P = 0.014) were significantly more in the unfavorable group. Overall, 29.2% of patients underwent conservative management with antibiotics alone, 25.0% underwent percutaneous needle aspiration (PNA), 49.1% underwent ultrasound-guided percutaneous drain (PCD) insertion and open surgical drainage (OSD) was needed in a single patient. The success rate was 100% for conservative management, 76.6% for PNA, 94.7% for PCD and 100% for OSD with an overall mortality of 2.5%.

CONCLUSIONS

Age-related leukocytosis, neutrophilia, elevated aspartate transaminase or alanine transaminase and hypoalbuminemia at presentation are predictors of poor outcomes in pediatric liver abscess. Protocol-based management leads to the appropriate use of PNA and PCD while decreasing mortality and morbidity related to either.

Ceftaroline and Daptomycin Combination Antibiotic Therapy for a Methicillin-Resistant Staphylococcus Aureus Liver Abscess in a Premature Infant

Staphylococcus aureus is a common bacterial etiology for infections in the neonatal intensive care unit (NICU). Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) can be difficult to treat, even when good source control is obtained. There are few data on treatment of MRSA abscess in the neonatal population. Vancomycin, clindamycin, daptomycin, ceftaroline, and linezolid are often used to treat MRSA infections in pediatric patients. Daptomycin and ceftaroline have been studied in adults as a salvage therapy for refractory MRSA infections. Few data exist on combination therapy for treatment of MRSA infection in neonatal or premature infant patients. This case report describes the successful use of intravenous (IV) daptomycin (6 mg/kg IV every 12 hours) plus ceftaroline (8 mg/kg IV every 8 hours) for 18 days after failure of daptomycin monotherapy to treat multiple hepatic abscesses and an infected thrombus caused by MRSA in a premature female born at 30 weeks of gestation. The patient had increased abscess size after daptomycin monotherapy and treatment was changed to combination therapy. With addition of the ceftaroline, the abscesses resolved entirely on ultrasonography within 3 weeks. While combination therapy was effective in this patient, additional research is needed to determine the most appropriate use for combination therapy for treatment of MRSA infections in the premature infant and neonatal population.

Liver abscesses in the Western pediatric population

Background and study aims: Liver abscesses are rare in the Western pediatric population and data on predisposing factors and etiology are scarce. We aimed to describe predisposing factors, microbiological characteristics, and treatment. Patients and methods: Retrospective analysis of children admitted to two tertiary care hospitals in Belgium from 1 January 1996 to 31 December 2019. We analyzed clinical features, predisposing factors, imaging characteristics, microbiological data, treatment, and outcome in children with a liver abscess and compared these data with the literature. Results: We collected 24 cases with a male to female ratio of 1.4 and a median age of 3.2 years at time of diagnosis. Survival was 95.8%. Invasive culture specimens were obtained in 83.3% and showed growth of bacteria in 55%. Parenteral antibiotics were administered before invasive culture sampling in 80%. Liver abscesses were cryptogenic in four (16.7%) patients. Hepatobiliary disease was the most prevalent predisposing factor (n = 6; 25%), followed by recent antineoplastic therapy for malignancies (n = 5; 20.8%), intra-abdominal surgical pathology (n = 4; 16.7%) and umbilical venous catheters (n = 2; 8.3%). In two patients there was a parasitic origin (n = 2; 8.3%) and in one it was caused by Bartonellosis. There was no diagnosis of chronic granulomatous disease (CGD) in our cohort. Conclusions: Pediatric liver abscesses have a favorable outcome in the developed world. Whenever feasible, invasive abscess culture specimens should be obtained. In patients presenting with a cryptogenic liver abscess or atypical disease course, immunological workup should be ensured.

Pediatric Hepatic Cystic Lesions: Differential Diagnosis and Multimodality Imaging Approach

When a pediatric hepatic cystic lesion is identified at imaging, the differential diagnosis may be broad, including developmental, infectious, neoplastic, and posttraumatic or iatrogenic causes. The location of a cystic lesion and its number, size, composition, and relationship to the biliary system are features that help in narrowing the differential diagnosis. An incidentally detected simple hepatic cyst is the most commonly encountered. Ciliated foregut cysts are typically located in hepatic segment IVa. The presence of multiple cysts should raise suspicion for fibropolycystic liver disease, a group of related lesions-including biliary hamartoma and choledochal cyst-caused by abnormal embryologic development of the ductal plate. Communication of the cystic lesion with the biliary tree can confirm the diagnosis of choledochal cyst. In a neonate with jaundice, a cystic lesion at the porta hepatis should raise suspicion for choledochal cyst versus cystic biliary atresia. Hepatic abscess can appear cystlike, though typically with internal contents. In an immunocompromised child, multiple cystlike lesions should raise concern for fungal microabscesses. A complex cystic mass in a young child should raise suspicion for mesenchymal hamartoma, which can evolve into undifferentiated embryonal sarcoma if untreated. Hepatic hematoma and biloma can appear cystlike in children with a history of trauma or recent intervention. In neonates with an umbilical vein catheter (UVC), an intrahepatic cyst along the course of the UVC should raise concern for infusate extravasation. Familiarity with imaging findings and clinical features is essential for achieving accurate diagnosis of pediatric hepatic cystic lesions, which in turn can guide appropriate clinical management. Online supplemental material is available for this article. ^©RSNA, 2022.

Point-of-Care Ultrasound Identification of Portal Vein Thrombosis in a Pediatric Patient

ABSTRACT

Abdominal pain is one of the most common presenting complaints encountered in the pediatric emergency department. The use of point-of-care ultrasonography by emergency physicians has been shown to expedite the diagnosis of a large variety of conditions and can be used to accurately identify intra-abdominal pathology in children. We describe the case of a pediatric patient who presented to the pediatric emergency department with acute abdominal pain, in whom point-of-care ultrasonography helped expedite the diagnosis of acute portal vein thrombosis and liver abscess.

Parasite-Induced Th2 Polarization—An Unusual Cause of Paediatric Hepatic Abscess

Liver abscess (LA) is a serious infectious disease, but is relatively rare in the paediatric population, especially in developed countries. Mostly, hepatic abscesses are pyogenic, caused by Staphylococcus aureus, while in extremely rare cases can be caused by parasites, such as Ascaris lumbricoides. Antimicrobial therapy and percutaneous drainage are the treatments of choice, lowering the mortality caused by this infection. We report a case of a 3-year-old girl admitted to the hospital for abdominal pain and a low-grade fever, with abdominal ultrasonography revealing a hepatic lesion. Initial laboratory tests showed moderate anaemia, thrombocytosis, eosinophilia, high inflammatory markers, and normal liver function. A computed tomography scan revealed two liver abscesses located subdiaphragmatically, and a high immunoglobulin E (IgE) value (22,300 U/mL). After excluding other possible etiologies, the patient was tested for parasitic infections. IgE for Ascaris lumbricoides came slightly higher. In addition to empirical antibiotic treatment, the patient received albendazole and made an uneventful recovery, with the full remission of the abscesses and without the need for drainage. In certain cases, parasites such as Ascaris lumbricoides are capable of inducing a T helper 2 (Th2) dominated immune response, predisposing the host to eosinophilia, hyperIgE, and increased susceptibility to bacterial infections. Early diagnosis and treatment in these cases may lead to less invasive therapy options in order to obtain a full recovery. To the best of our knowledge, this is the only reported case in the literature of a paediatric patient with parasite-induced liver abscesses, with extremely high IgE values, minimal symptomatology, that made a fast, full recovery without the need of drainage.

A fatal case of liver abscess caused by hypervirulent Klebsiella pneumoniae in a diabetic adolescent: A clinical and laboratory study

IMPORTANCE

Hypervirulent variants of Klebsiella pneumoniae (hvKp) are capable of causing life-threatening pyogenic liver abscesses (PLAs), but hvKp caused PLAs was seldom reported in pediatric populations. Hence, there is an urgent need to raise our awareness of this phenomenon in pediatric populations.

OBJECTIVE

This study aimed to report the clinical characteristics of hvKp that caused fatal PLA complicated by bacteremia in an adolescent and further identify the microbiological and genomic features of the causative strain.

METHODS

A 14-year-old boy with diabetes mellitus was admitted to our hospital with a diagnosis of PLA complicated by bacteremia. A hypermucoviscous hvKp strain, KPN_19-106, was isolated from the drainage fluid present within the liver abscess cavity and blood. The hypermucoviscosity phenotype of the causative strain was determined by string test. Its virulence was measured using serum resistance assay and Galleria mellonella larvae-killing assay. Antimicrobial susceptibility was determined by broth microdilution method. Genetic information was obtained by whole-genome sequencing and bioinformatics analysis.

RESULTS

KPN_19-106 belonged to sequence type 380 and serotype K2 and exhibited stronger serum resistance and higher in vivo lethality than the well-characterized hvKp NTUH-K2044 strain. Although KPN_19-106 is susceptible to most antibiotics, no sign of improvement was observed during treatment with such drugs. Whole-genome sequencing revealed that the isolate had integrated multiple mobile genetic elements related to virulence.

INTERPRETATION

Antibiotic-susceptible hvKp can cause fatal PLA complicated by bacteremia in adolescents, with no improvement during antimicrobial therapy. The causative strain in this case had integrated multiple virulence genes and thus exhibited higher virulence both in vitro and in vivo when compared with NTUH-K2044.

Liver Abscess in Children-experience From a Single Tertiary Care Center of North India: Etiology, Clinical Profile and Predictors of Complications

BACKGROUND

Liver abscess (LA), a common problem in children in the tropics, is believed to be mostly pyogenic (PLA), sometimes amebic (ALA). We aimed to analyze the clinical profile, etiology, risk factors for complications, management and outcomes of LA in children.

METHODS

The details of 81 children with LA managed in a tertiary set up over a period of 3 years were analyzed. A comparison of different parameters was performed with respect to etiology and complications.

RESULTS

ALA, PLA and mixed infection LA were diagnosed in 40 (49.4%), 32 (39.5%) and 9 (11.1%) children. The triad of fever, hepatomegaly and right upper quadrant tenderness was seen in 65 (80.2%). Coagulopathy was observed in 60 (77%) and jaundice in 12 (14.8%). Majority (71.6%) had a single LA in the right lobe (69%). Conservative, percutaneous needle aspiration, percutaneous catheter drainage and surgical drainage were done in 11.1%, 3.7%, 82.7% and 2.5%, respectively. Forty-three (53.1%) had complicated LA with rupture in 55.8% and vascular thrombosis in 16.2%. Children with complicated LA had higher alanine transaminase, prolonged prothrombin time/international normalized ratio, low serum protein and albumin levels (P < 0.05). Median duration of follow-up was 2 months and mean time to resolution of LA was 48.5 ± 18 days.

CONCLUSIONS

ALA is the commonest cause of pediatric LA in endemic regions and is difficult to differentiate from PLA clinically. Percutaneous catheter drainage is safe and effective modality for the management of LA in children. A higher alanine transaminase, prolonged prothrombin time/international normalized ratio and low serum albumin levels (<3 g/dL) at presentation identify complicated LA.

Abiotrophia defectiva liver abscess in a teenage boy after a supposedly mild blunt abdominal trauma: a case report

Background

A pyogenic liver abscess (PLA) represents a pus-filled cavity within the liver parenchyma caused by the invasion and multiplication of bacteria. The most common offender isolated from the PLA in children is Staphylococcus aureus. Abiotrophia defectiva is a Gram-positive pleomorphic bacterium, commonly found in the oral cavity, intestinal, and genitourinary mucosa as part of the normal microbiota. It has been proven to be an etiological factor in various infections, but rarely in cases of PLA. The case presented here is, to the best of our knowledge, the first pediatric case of PLA caused by A. defectiva.

Case presentation

A 13-year-old Caucasian boy presented with a two-day history of abdominal pain, fever up to 40 °C, and polyuria. Contrast-enhanced computed tomography (CT) scan revealed a single, multiloculated liver lesion, suggestive of a liver abscess. The boy had sustained a bicycle handlebar injury to his upper abdomen 3 weeks before the symptoms appeared and had been completely asymptomatic until 2 days before admission. He was successfully treated with antibiotic therapy and open surgical drainage. A. defectiva was isolated from the abscess material. Histopathology report described the lesion as a chronic PLA.

Conclusions

A. defectiva is a highly uncommon cause of liver abscess in children. In such cases, various predisposing factors should be considered, including antecedent blunt abdominal trauma.

Incidence Trends, Comorbidities, and Outcomes of Pyogenic Liver Abscess Among Children: A Nationwide Population-based Analysis

OBJECTIVES

Population-based analysis of incidence, comorbid conditions, microbiological characteristics, and outcomes of pyogenic liver abscess (PLA) in children.

METHODOLOGY

Retrospective analysis of National Inpatient Sample (NIS) and Kids Inpatient database (KID) database from 2003 to 2014 and included patients between 1 and 20 years of age. Using ICD-9 codes, we identified all hospitalizations with PLA and compared them with 1 : 10 age- and gender-matched controls. Amebic liver abscess and Candida infections were excluded.

RESULTS

Total number of PLA admissions is 4075. The overall incidence of PLA is 13.5 per 100,000 hospitalizations, which increased by 60% between 2003 and 2014. The mean age of patients was 13.03 ± 6.1 years and were predominantly boys-61%. Of the comorbid conditions, hepatobiliary malignancy had the highest odds ratio (OR 71.8) followed by liver transplant (OR 38.4), biliary disease (OR 29.9), inflammatory bowel disease (IBD) (OR 5.35), other GI malignancies (OR 4.74), primary immune deficiency disorder (OR 4.13). Patients with PLA had 12 times increased odds of having associated severe sepsis. Infective endocarditis (IE) (OR 4.5), appendicitis (OR 1.8), and diverticulitis (OR 8.1) were significantly associated with PLA. Almost 39% (1575) of the PLA patients had positive culture, whereas Streptococcus (10.8%) and Staphylococcus spp (9.2%) were the most common pathogens. About 45% of PLA patients underwent percutaneous liver abscess aspiration whereas 4.1% had hepatic resection for PLA. The mortality rate of PLA was 0.8% (n = 32).

CONCLUSIONS

The incidence of PLA is steadily increasing over the last decade among pediatric population in the United States. Hepatobiliary malignancy and liver transplant are the most common comorbid conditions associated with PLA.

Detection of spleen abscesses facilitates diagnosis of melioidosis in Malaysian children

OBJECTIVES

Melioidosis is associated with extremely high case fatality ratios. The aim of this study was to determine whether detection of abdominal visceral abscesses can facilitate diagnosis of melioidosis in children.

METHODS

We conducted a retrospective analysis of all children who had liver and/or spleen abscesses on abdominal ultrasonography admitted to Bintulu Hospital in Sarawak, Malaysia, from January 2014 until December 2018.

RESULTS

Fifty-three children had liver and/or spleen abscesses. Spleen abscesses were present in 48 (91%) cases; liver abscesses in 15 (28%). Melioidosis was confirmed by culture in 9 (17%) children; small occult splenic abscesses were present in all cases. In 78% of these cases, the lesions were detected before any positive culture (or serology) results were available. Four (8%) children had bacteriologically-confirmed tuberculosis. Two (4%) had Staphylococcus aureus infection. Of the remaining 38 (72%) culture-negative cases, 36 (95%) had clinical and imaging characteristics similar to that of children with culture-confirmed melioidosis and improved with empirical melioidosis antibiotic therapy.

CONCLUSIONS

A large number of children in Bintulu Hospital in Sarawak, Malaysia, were found to have spleen abscesses. Melioidosis was the most common etiology identified in these children. Abdominal ultrasonography is extremely useful in facilitating the diagnosis of pediatric melioidosis.

Paediatric liver ultrasound: a pictorial essay

Ultrasound scan is a painless and radiation-free imaging modality and, therefore, it is widely considered the first-choice diagnostic tool in the setting of hepatopathies in paediatric patients. This article focuses on the normal ultrasound anatomy of the liver in neonatal and paediatric age and reviews the ultrasound appearance of the most common diffuse and focal liver affections.

Pediatric Liver Abscess: Trends in the Incidence, Etiology, and Outcomes Based on 20-Years of Experience at a Tertiary Center

Background: Liver abscess is an important but relatively rare disease in children. This study investigated the clinical characteristics of eligible patients at a referral tertiary center over the past two decades. Method: A 20-year retrospective study (January 2000-December 2019) enrolled 38 children diagnosed with liver abscess. Demographic data; clinical features; laboratory, imaging, and microbiological findings; management strategy; and outcomes were reviewed from the patients' medical records. Results: Thirty-eight cases of pyogenic liver abscess were identified without a culture-proven amebic or fungal abscess. The mean age of diagnosis was 9.6 ± 6.2 years, and the male-to-female ratio was 1.92: 1. Hemato-oncological (28.9%) and predisposing hepatobiliary diseases (23.7%) were the two most common predisposing factors. Fever (94.7%) was the most common presentation followed by right upper quadrant abdominal pain (42.1%) and pleural effusion (34.2%). Among the laboratory parameters, leukocytosis was common (70.3%), and all patients had elevated serum C-reactive protein levels. Increased serum levels of alanine aminotransferase, aspartate aminotransferase, direct bilirubin, and total bilirubin were found in 40.5, 48.6, 23.1, and 42.9% of the cases, respectively. The most common pathogen in blood and pus cultures was Klebsiella pneumoniae. The mean durations of intravenous antibiotic and total antibiotic use were 29.0 ± 15.7 and 45.1 ± 22.1 days, respectively. Twelve patients (31.6%) were treated with antibiotics alone, while percutaneous needle aspiration, percutaneous pigtail drainage, and surgical intervention were performed in 12 (31.6%), 10 (26.3%), and 5 (13.2%) patients, respectively. No mortality was documented in this series. Conclusion: The present study reflects a relatively declining incidence of liver abscess compared with prior studies in Taiwan. K. pneumoniae remains the most prevalent pathogen in both blood and abscess cultures in Taiwan. Proper antimicrobial therapy with timely drainage generally yielded an adequate treatment response without any mortality.

Tubercular liver abscess rupturing into the pleural cavity: a rare complication

Liver abscesses, either pyogenic or amoebic, with or without the involvement of the pleura, are not infrequently encountered in children. Isolated tubercular liver abscess without active pulmonary, gastrointestinal or other clinical evidence of tuberculosis is, however, rare and more so its rupture into the pleura. We report a case of a 14-year-old girl who presented with a liver abscess rupturing into the pleura causing an empyema. Successful management was achieved by intercostal tube drainage and antitubercular treatment.

A cohort study of age and sex specific risk of pyogenic liver abscess incidence in patients with type 2 diabetes mellitus

To investigate the age-sex-specific incidence and relative risk of pyogenic liver abscess (PLA) in patients with type 2 diabetes mellitus (T2DM), and to assess the joint effects of T2DM and other clinical risk factors for PLA on PLA incidence. We used a population-based cohort design with Taiwan's National Health Insurance claim data. Study subjects included 613,921 T2DM patients and 614,613 controls identified in 2000 and were followed to the end of 2010. Cox regression model was employed to calculate the hazard ratio (HR) and 95% confidence interval (CI) of PLA in relation to T2DM. Over an 11-year follow-up, 5336 T2DM and 1850 controls were admitted for PLA, representing a cumulative incidence of 0.87% and 0.30%, respectively. T2DM was significantly associated with increased hazard of PLA (HR, 2.88; 95% CI, 2.73-3.04). We also found that age and gender may significantly modify the relationship between T2DM and PLA, with a higher HR noted in males patients and those aged <45 years. Biliary tract diseases (HR, 8.60; 95% CI, 7.87-9.40) and liver cirrhosis (HR, 7.52; 95% CI, 6.58-8.59) may add substantially additional risk to the incidence of PLA in T2DM patients. The increased risk of PLA in T2DM was greater in male and younger patients. Careful management of biliary tract diseases and liver cirrhosis may also help reduce the incidence of PLA in T2DM patients.

Pyogenic liver abscess due to hypervirulent Klebsiella pneumoniae in a 14-year-old boy

A 14-year-old otherwise healthy boy presented with right-sided back pain following high fever. Abdominal computed tomography scan showed a large liver abscess. Klebsiella pneumoniae (KP) was rapidly identified from peripheral blood using the melting temperature mapping (Tm) method, which enables identification of pathogenic microorganisms within four hours after patient sample collection. He was diagnosed with pyogenic liver abscess (PLA) caused by KP on the day of admission. The KP was the hypervirulent (hv) clinical variant (string test positive, serotype K1, sequence type 23, rmpA and magA positive). After intravenous antibiotic therapy and drainage of the abscess, his condition resolved. The highlights of this case report are a healthy child with hypervirulent Klebsiella pneumoniae liver abscess in Japan and the new Tm mapping method for rapid and accurate identification of the pathogenic microorganism.

Host-derived fatty acids activate type VII secretion in Staphylococcus aureus

The type VII secretion system (T7SS) of Staphylococcus aureus is a multiprotein complex dedicated to the export of several virulence factors during host infection. This virulence pathway plays a key role in promoting bacterial survival and the long-term persistence of staphylococcal abscess communities. The expression of the T7SS is activated by bacterial interaction with host tissues including blood serum, nasal secretions, and pulmonary surfactant. In this work we identify the major stimulatory factors as host-specific cis-unsaturated fatty acids. Increased T7SS expression requires host fatty acid incorporation into bacterial biosynthetic pathways by the Saureus fatty acid kinase (FAK) complex, and FakA is required for virulence. The incorporated cis-unsaturated fatty acids decrease Saureus membrane fluidity, and these altered membrane dynamics are partially responsible for T7SS activation. These data define a molecular mechanism by which Saureus cells sense the host environment and implement appropriate virulence pathways.

Management of Liver Abscess in Children: Our Experience

Introduction

Liver abscess is common in pediatric population in India. Children have unique set of predisposing factors and clinical features. Liver abscesses are infectious, space-occupying lesions in the liver; the two most common abscesses being pyogenic and amebic. Its severity depends on the source of the infection and the underlying condition of the patient.

Materials and methods

A total of 34 patients less than 12 years were assessed in a retrospective study from January 2012 to 2016. Patients were assessed in terms of age of presentation, etiology, bacteriology, diagnosis, and modality of treatment.

Results

The mean age of presentation was 6.3 years. Average volume of abscess was 164 cc. Nine patients (26.4%) underwent percutaneous needle aspiration under ultrasound guidance with wide bore needle (18 G disposable needle). Three patients required more than two sittings of aspiration. Patients with volume more than 80 cc were treated with catheter drainage. Twenty patients (58.8%) underwent ultrasound-guided percutaneous catheter drainage. Two patients required catheter drainage for large abscess and needle aspiration for the smaller abscess.

Conclusion

Antimicrobial therapy along with percutaneous drainage constitutes the mainstay of treatment, whereas open surgical drainage should be reserved for selected cases.How to cite this article: Waghmare M, Shah H, Tiwari C, Khedkar K, Gandhi S. Management of Liver Abscess in Children: Our Experience. Euroasian J Hepato-Gastroenterol 2017;7(1):23-26.

Immunohistochemistry and Special Stains in Medical Liver Pathology

Histochemical and immunostains are routinely used to evaluate medical liver biopsy specimens. The use of these special stains allows the identification of more clinically important information than is available on hematoxylin and eosin stains alone. These special stains are important for evaluating active and chronic injury and for establishing a specific diagnosis. The skillful use of these stains greatly improves patient care. Information on the use of special stains can be scattered in different sources, making the information hard to access. In this article, the use of special stains in medical liver biopsies is concisely reviewed.

Protocol-based management of 154 cases of pediatric liver abscess

AIM

Although liver abscess (LA) is prevalent worldwide, especially in developing countries, there is a paucity of data regarding the protocol for management of LA in children. The aim of this study was to analyze the outcome of a protocol-based management of pediatric LA from a single institution.

MATERIALS AND METHODS

This prospective observational study was conducted in a tertiary-care children's hospital and included all patients with LA managed over a 5-year period. Detailed clinical, laboratory, microbiological and imaging parameters were recorded, and the patients were treated according to a standardized management protocol. Small abscesses (<5 cm) and those with solid appearance on initial ultra-sonogram (US) were managed with antimicrobial therapy alone. Liquefied abscesses on imaging were additionally subjected to US guided percutaneous needle aspirations (PNA). Large abscesses pointing to the surface were treated by percutaneous drainage (PCD). Ruptured LA, abscess inaccessible to image-guided drainage and those not responding to other modes of treatment were subjected to open surgical drainage (OSD). Pleural collections were treated by aspirations or intercostal tube drainage. Outcome was analyzed in terms of duration of recovery and complications including mortality.

RESULTS

Over the 5-year period, 154 pediatric LA patients underwent protocol-based management. The mean age of the patients was 6.76 years with the male:female being 1.26:1. Medical management alone, PNA, PCD and OSD were successful in 38 (24.6%), 76 (49.3%), 11 (7.14%) and 29 (18.8%) cases, respectively. Pleural collections developed in 43 (27.9%) patients out of which aspiration/drainage was needed in 24 (55.81%) cases. The mean duration of hospital stay was 20.67 ± 9.52 days. Ongoing sepsis and multi-organ failure lead to mortality in 6 (3.8%) cases; rest of the patients were doing well on follow-up.

CONCLUSION

Ultra-sonography was useful for the initial diagnosis, monitoring the progress and management of LA in children. The outcome of a protocol-based management of LA in children was favorable.

Liver abscess in a boy with hyper IgE syndrome

Hyper immunoglobulin-E syndrome is a rare primary immunodeficiency disease, characterized by the classical triad of recurrent staphylococcal skin abscesses, pneumonia with pneumatocele formation, and elevated levels of serum IgE, usually over 2000 IU/mL. Chronic granulomatous disease, hyper IgE, and complement deficiencies are immunopathologies known to be associated with liver abscesses. We present a 2 ½-year-old boy with liver abscess and associated hyper IgE.

Gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy in the years 2000

AIM: To review gastrointestinal and liver infections in children undergoing antineoplastic chemotherapy. To look at gut microflora features in oncology children.

METHODS: We selected studies published after year 2000, excluding trials on transplanted pediatric patients. We searched English language publications in MEDLINE using the keywords: “gastrointestinal infection AND antineoplastic chemotherapy AND children”, “gastrointestinal infection AND oncology AND children”, “liver infection AND antineoplastic chemotherapy AND children”, “liver abscess AND chemotherapy AND child”, “neutropenic enterocolitis AND chemotherapy AND children”, “thyphlitis AND chemotherapy AND children”, “infectious diarrhea AND children AND oncology”, “abdominal pain AND infection AND children AND oncology”, “perianal sepsis AND children AND oncology”, “colonic pseudo-obstruction AND oncology AND child AND chemotherapy”, “microflora AND children AND malignancy”, “microbiota AND children AND malignancy”, “fungal flora AND children AND malignancy”. We also analysed evidence from several articles and book references.

RESULTS: Gastrointestinal and liver infections represent a major cause of morbidity and mortality in children undergoing antineoplastic chemotherapy. Antineoplastic drugs cause immunosuppression in addition to direct toxicity, predisposing to infections, although the specific risk is variable according to disease and host features. Common pathogens potentially induce severe diseases whereas opportunistic microorganisms may attack vulnerable hosts. Clinical manifestations can be subtle and not specific. In addition, several conditions are rare and diagnostic process and treatments are not standardized. Diagnosis may be challenging, however early diagnosis is needed for quick and appropriate interventions. Interestingly, the source of infection in those children can be exogenous or endogenous. Indeed, mucosal damage may allow the penetrance of endogenous microbes towards the bowel wall and their translocation into the bloodstream. However, only limited knowledge of intestinal dysbiosis in oncology children is available.

CONCLUSION: The diagnostic work-up requires a multimodal approach and should be implemented (also by further studies on new biomarkers) for a prompt and individualized therapy.

Pyogenic Liver Abscess with Delayed Presentation After Appendectomy

Liver abscess is a serious condition that is uncommon in otherwise normal children. Predisposing factors include immunosuppression, surgery and travel to certain areas. We present a patient with liver abscess 4 months after appendectomy. In addition, we reviewed 7 cases of liver abscess that occurred in a 22-year period.

Gastrointestinal Fistulization in Amebic Liver Abscess

BACKGROUND

Liver abscess is a common deep seated abscess in children; amebic liver abscess is associated with more local complications.

CASE CHARACTERISTICS

We report two preschool children presenting with short history of pain, fever and right upper quadrant pain. The abscess communicated with gastro-intestinal tract (ascending colon in case 1 and duodenum in case 2), and diagnosis of amebic liver abscess was confirmed by DNA PCR.

OUTCOME

Both children were successfully managed with intravenous antibiotics and catheter drainage.

MESSAGE

Gastrointestinal fistulization may be rarely seen in amebic liver abscess. Conservative management with antibiotics, catheter drainage and supportive care may suffice.

[Particularities of liver abscesses in children in Senegal: Description of a series of 26 cases]

Liver abscess is a serious infection that can cause life-threatening complications.

OBJECTIVE

To describe the epidemiology, diagnosis, and progression of liver abscess at the Dakar National Albert-Royer Children's Hospital.

METHOD

A retrospective study was conducted from over a period of 5 years (1st January 2010 to 31st December 2014). All children aged 0-15 years hospitalized for liver abscess with ultrasound confirmation were included. We collected demographic data (age, gender, socioeconomic status, origin), clinical data (general and hepatic symptoms), diagnostic data (ultrasound, bacteriology) and progression (death, complications, sequelae). The data were analyzed with Epi-info (P<0.05 was considered significant).

RESULTS

We collected 26 cases of liver abscesses, representing a hospital prevalence of 100 cases per 100,000 admissions. Males predominated (sex ratio: 1.36). The children's average age was 7.2 years. Most of the children came from urban areas of Dakar. Low socioeconomic status and precarious lifestyle were the contributing factors. Anemia (69.2%), malnutrition (42.3%), and abdominal trauma (15.3%) were the main causes found. The Fontan triad characteristic of the liver abscess was found in 57.7% of cases. At ultrasound, a single abscess was found in 21 cases. The abscess was located in the right lobe in 18 cases, the left lobe in three cases, and in both lobes in three cases. Segment VI (four cases) was the most frequently involved. Bacteriologically, the abscess was pyogenic in 17 cases and an amoebic abscess in nine cases. The main pyogenic sources found were Klebsiella pneumoniae in two cases, Pseudomonas aeruginosa in one case, Streptococcus pneumoniae in one case, and Staphylococcus aureus in one case. The average duration of antibiotic treatment was 14.5 days. Liver drainage was carried out in 24 cases. The outcome was favorable in all children.

CONCLUSION

The prevalence of liver abscesses at the Albert-Royer Children's Hospital is relatively high, compared to the literature data. Percutaneous drainage combined with antibiotics remains the treatment of choice. The prognosis is favorable.

Fatal case of amoebic liver abscess in a child

We reported a case of amoebic liver abscess (ALA) in a 6-year-old Malaysian boy who presented with fever, lethargy, diarrhoea and right hypochondriac pain. On admission he was diagnosed with perforated acute appendicitis and a laparotomy was done. After surgery he developed acute respiratory distress. Ultrasonography, chest X-Ray and CT scan revealed two ALAs in the posterior segment of right lobe of liver, pleural effusion and collapsed consolidation of lungs bilaterally. Percutaneous liver abscesses drainage was done and intravenous Metronidazole was started. PCR carried out on the pus from the abscess was positive for Entamoeba histolytica. Patient however succumbed to the infection one week after admission.

A case of pyogenic liver abscesses in a previously healthy adolescent man

An 18-year-old, previously healthy man admitted with abdominal pain, high-grade fevers, nausea and emesis was found to have multiple hepatic abscesses. Aspiration cultures grew Fusobacterium necrophorum, a rare bacterium causing potentially fatal liver abscesses in humans. Following sequential percutaneous drainages and narrowing of antibiotics, the patient was discharged on a 6-week antibiotic course and showed no signs of infection. A week after presentation it was discovered that he had experienced upper respiratory symptoms and sore throat prior to presentation. Because oropharyngeal infections are a potential source of bacteremia, they must be considered in the differential diagnosis of patients presenting with hepatic abscesses and no evidence of immunocompromise.

Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses.

Liver Abscesses and Hyper IgM Syndrome

Hyper IgM (HIGM) syndrome is an immunodeficiency that can lead to liver disease in more than 80% of affected males by an age of 20 years. Hepatitis, sclerosing cholangitis, and hepatocellular malignancies are common among them. We encountered two cases in children of less than 12 years who presented with typical manifestations of liver abscess and were later detected to have a concomitant underlying HIGM syndrome.