Case Report on Pyogenic Liver Abscess

Introduction

Pyogenic liver abscess (PLA) is considered as an unusual condition, with an incidence of 2.3 cases per 100,000 people. Pyogenic liver abscess is described as “ a pocket of pus that forms in the liver due to a bacterial infection.” An abscess is usually accompanied by swell and inflammation in the surrounding area which causes pain and swelling in the abdomen.¹

They are characterized as acute and chronic disease with symptoms of fever, lethargy, right upper quadrant pain, anorexia, pleural effusion, enlarged liver and jaundice, which can be fatal if not treated promptly. Commonly found pathogens in oropharyngeal flora, includes Streptococcus species and Escherichia coli and Klebsiella in Asia which are positive in blood culture of more than 50% of the cases.³ In this case report, patient showed positive growth results for the anaerobic culture - Isolate 1: Bacteroides fragilis and Isolate 2: Peptostreptococcus species.

PLA is an uncommon disease in the adolescent population and more common in patients aged 65 years or older. Compared to males, female population with a history of biliary disease is susceptible to infection. Patients with diabetes mellitus are 3.6 times more susceptible to this condition in accordance to the article published in Clinical Infectious Diseases.²

PLA usually occurs through the hematogenous and biliary spread and previous reports suggest that biliary diseases (eg: stones, cholangiocarcinoma) are the most common causes which have been associated with E. coli, affecting the liver, pancreas, and gallbladder. Other causes are colonic diseases (eg: diverticulitis, appendicitis, Crohn’s disease), pancreatitis, infection of the blood, cryptogenic disease, intra-abdominal sepsis.⁵ Certain risk factors including diabetes, underlying hepatobiliary or pancreatic disease, history of the liver transplant, and chronic use of proton-pump inhibitors (PPI) are typically present in patients with pyogenic liver abscesses.¹

Diagnosis consists of a combination of blood cultures and imaging tests including an abdominal ultrasound to locate the abscess, a CT scan with intravenous contrast or injected dye to find and measure the abscess, an MRI of the abdomen, and a blood test to look for signs of infectious inflammation and cultures of blood for bacterial growth to determine the course of antibiotics.² Treatment consists of antibiotics (Penicillins, Aminoglycosides, Metronidazole, Cephalosporins), percutaneous drainage under USG or CT control and surgery (Laparotomy in intra-abdominal disease), or combination therapy of combined antibiotics regimen and surgical intervention (aspiration, drainage or resection), except for small abscesses which are treated with antibiotics only.¹

Case Report

An 80-year-old female patient presented with pain in the right upper abdomen (1 week) and vomiting (multiple episodes with the content of blood and food particles). She had a history of significant weight loss, fever, and decreased appetite (1 week). Her medical history revealed a hydatid cyst of the liver which was treated many years back with IV antibiotics, secondary bacterial infection two years back which was aspirated, and Type 2 diabetes mellitus (DM).

General examination revealed a poorly built and moderately nourished patient with blood pressure (110/70 mmHg), (150/90 mmHg), temperature- afebrile and respiratory rate: 18/min, pulse rate: 70 b/m. On systemic examination, per abdomen (PA), epigastric tenderness was present. Results of laboratory investigations were as follows, Haemoglobin: 11.6 g/dl, 10.5 g/dl, MCHC: 32.2 g/dl, 32.4 g/dl, Red blood cell count: 3.82 million/cumm, Packed cell volume: 34.9%, 32.3%, Platelet count: 7,46,000/cumm, 5,82,000/cumm, Leucocyte count total: 19,000/cummm, 13,200/cumm, Lymphocyte: 11%, Neutrophil: 82%, Sr. Creatinine: 0.40 mg/dl, 0.39 mg/dl, Sr. aspartate transaminase (SGOT): 27IU/L, Sr. alanine transaminase (SGPT): 10 IU/L, Albumin: 2.87 g/dl, 2.17 g/dl, Globulin: 4.2 g/dl, A/G ratio: 0.5, Sr. alkaline phosphatase: 66 IU/L, total bilirubin: 0.22 mg/ dl, Sr. total protein: 6.35 g/dl, Sr. sodium: 130 mEq/L, 129 mEq/L, Sr. chloride: 91.3 mEq/L.

Blood culture test showed a positive growth for the anaerobic culture with Isolate 1: Bacteroides fragilis and Isolate 2: Peptostreptococcus species. Gastric biopsy paraffin method was carried out which revealed absence of conclusive evidence of malignancy in the gastric mucosal section. Cytology of body fluid revealed features of pyogenic liver abscess, which includes dense inflammatory infiltrate composed of predominantly neutrophils, along with few lymphocytes and macrophages in a background of necrotic debris, bacterial colonies and few RBCs. UGI Scopy showed severe esophagitis, extrinsic impression in body and antrum of stomach, pus pointing in one point in antrum, infiltration into pylorus with obstruction.

Computerized Tomography (CT) scan of abdomen and pelvis showed evidence of peripherally enhancing cystic lesion measuring 8×7 cm in segment IV with wall thickness of 8 mm showing calcifications within. Multiple thick septations were observed. It showed exophytic projections impinging on the wall of the stomach in the region of pylorus. There was a narrowing in the region of pylorus. Stomach wall thickening (likely inflammatory/ infective cause), small adjacent lymph nodes (measuring 10 mm and 8 mm) were also noted in the region of pylorus over a length of 51 mm. Thickened stomach showed layered pattern of enhancement. Enlarged vessels were noted around the thickened stomach. Rest of the stomach showed increased enhancement of wall. Oesophagus was also mildly dilated. Gall bladder was displaced by large liver lesion. Liver showed pocket of fluid noted in left para colic gutter. Bilaterally, pleural fluid was found along with mild interstitial thickening involving segment of lung bases. The following images (Figure 1-5) shows different phases of CT abdomen and pelvis of the patient which includes size and location of abcess in the liver.

The treatment started with antibiotic therapy including Inj. Ciprofloxacin 100 ml BD, Inj. Metronidazole 100 ml TID, Inj. Piperacillin + Tazobactum 4.5 gm TID, syrup containing 0.1g of liver fraction, syrup of fungal diastase + pepsin, and other supportive medications. This was followed by drain care during five days of hospitalisation. The condition of the patient improved during hospital stay with no further complications and she was discharged with stable vitals.

Discussion

Pyogenic liver abscess is a rare disease that is more commonly found in the elderly and rare in adolescence. In Hong Kong, the geriatric population is growing continuously and the role of advanced age in PLA could be a significant issue.⁴ PLA is estimated to have an annual incidence of 2.3 cases per 100,000 in the general population with a predominance of cases in males, with a male:female ratio of 1.3:1. It is even more common amongst hospitalized patients, with one review showing an incidence of 8-22 cases per 100,000 hospital admissions.¹

Liver abscesses are more commonly pyogenic or amoebic. Pyogenic abscesses may be caused mainly by ascending biliary (gallstones, cholangitis, and malignancies) or portal tract sepsis (diverticulitis, inflammatory bowel disease, intra-abdominal inflammation, and malignancies) and to a lesser degree by superinfection of cysts or necrotic tissue, trauma, or hematogenous dissemination. The most common pathogens are Streptococcus species (29.5%), E. coli (18.1%), Staphylococcus species (10.5%) and Klebsiella (9.2%).³ The observed signs and symptoms of the disease are fever and chills, diarrhoea, right upper quadrant pain, respiratory symptoms, confusion, jaundice, hepatomegaly, and pleural effusion.⁴ Several concomitant co-morbid conditions have been associated with PLA including diabetes mellitus, biliary disease, hypertension, intra-abdominal infection, immunosuppression, pancreatic disease, liver transplant, malignant stricture, and inflammation of the gastrointestinal tract.³

In the present case, a female patient presented with upper abdominal pain, decreased appetite for one week, and multiple episodes of vomiting with the content of blood and food particles. The patient also had a history of fever, significant weight loss, and decreased appetite. On recording the past history of the patient, history of hydatid cyst of the liver (treated many years back) and secondary bacterial infection two years back (aspirated), and co-morbidity of type 2 DM were noted.

The patient showed a positive growth results for the anaerobic culture- Isolate 1: Bacteroides fragilis and Isolate 2: Peptostreptococcus species. With reference to laboratory investigations, the impression of cytology of body fluid procedure/test showed features of pyogenic liver abscess. She was started on NG (nasogastric) feeds and later tolerated oral feeds well. The treatment was initiated with IV antibiotics including injection ciprofloxacin 100 ml BD, injection metronidazole 100 ml TID, injection piperacillin + tazobactam 4.5gm TID. The patient’s condition improved with no other further complications.

Conclusion

As several bacteria cause liver abscess, PLA requires prompt diagnosis and management of abdominal and other related infections to reduce the risk of developing further complications and mortality.

Conflict of Interest

None.