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A three year old Balinese boy was admitted to the department of child health, Sanglah hospital, denpasar, Bali with main complaint of the right-upper abdominal distension with pain, fever, and loss of appetite. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin was clear and hypoechoic area was observed around it. After an uneventful post open surgical drainage, the child was discharged in good condition.
A three year old Balinese boy was admitted to the department of child health, Sanglah hospital, denpasar, Bali with main complaint of the right-upper abdominal distension with pain, fever, and loss of appetite. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin was clear and hypoechoic area was observed around it. After an uneventful post open surgical drainage, the child was discharged in good condition.
A three year old Balinese boy was admitted to the department of child health, Sanglah hospital, denpasar, Bali with main complaint of the right-upper abdominal distension with pain, fever, and loss of appetite. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin was clear and hypoechoic area was observed around it. After an uneventful post open surgical drainage, the child was discharged in good condition.
*Department of Child Health, **Department of Pediatrics Surgery, ***Department of Radiology Medical Faculty of Udayana University, Sanglah Hospital, Denpasar, Bali
Abstract: Pyogenic liver abscess is one of the common liver abscesses. Worldwide, pyogenic liver abscess is much less common than amoebic abscess, but in Western communities, pyogenic liver abscess is more frequent. Pyogenic liver abscesses are rare in children. A three year old Balinese boy was admitted to the Department of Child Health, Sanglah Hospital on February 13, 2002 with main complaint of the right-upper abdominal distension with pain, fever, and loss of appetite. Laboratory results were leucocytosis, anaemia, elevated erythrocyte sedimentation rate (ESR), normal serum transaminase, normal serum bilirubin, albumin more than 2g/dl, and negative amoeba serology. The abdominal X-ray revealed elevated right hemidiaphragm. Liver ultrasonography revealed elevated right hemidiaphragm. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin was clear and hypoechoic area was observed around it. Pus gram stain showed gram-negative bacilli bacteria. The culture pus revealed Enterobacter aerogenes. An open surgical drainage was performed, combined with broad- spectrum antibiotic therapy. The single pyogenic liver abscess was in the right liver. After an uneventful post open surgical drainage, the child was discharged in good condition. The prognosis was good. Key words: pyogenic liver abscess Abstrak: Abses piogenik hati adalah salah satu abses hati yang paling sering ditemui. Umumnya abses piogenik hati lebih jarang ditemui disbanding abses amuba, tetapi di populasi Barat, abses piogenik lebih sering dijumpai. Abses piogenik jarang dijumpai pada anak. Seorang anak laki-laki berusia 3 tahun dating ke Bagian Kesehatan Anak Rumah Sakit Umum Sanglah pada tanggal 13 Februari 2002 dengan keluhan utama kembung pada bagian kanan atas perut disertai dengan nyeri, demam, dan hilangnya nafsu makan. Hasil laboratorium menunjukkan leukositosis, anemia, ESR meningkat, serum transaminase normal, serum bilirubin normal, albumin > 2g/dl, dan uji serologi amuba negatif. Foto abdomen menunjukkan hemidiafragma kanan yang meninggi. USG hepar menunjukkan massa padat di parenkim kanan hepar, berbatas tegas, dikelilingi daerah hypoechoic. Pewarnaan gram dari pus memperlihatkan bakteri basillus gram negatif. Kultur pus menghasilkan Enterobacter aerogenes. Telah dilakukan operasi drainase terbuka, digabungkan dengan terapi antibiotik spectrum luas. Pascaoperasi, pasien dipulangkan dalam keadaan baik. Prognosis kasus ini baik. Kata kunci: abses piogenik hepar CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 456 Introduction Pyogenic liver abscess is one of the common liver abscesses. Worldwide, pyogenic liver abscess is much less common than amoebic abscess, but in Western communities, pyogenic liver abscess is more frequent. Pyogenic liver abscesses are rare in children. 1-3 Pyogenic Liver Abscess (PLA) continues to be a significant source of morbidity in the pediatric population. 4
Although early reports in Milwaukee Childrens Hospital between 1957-1977 quoted an incidence of 3 in 100,000 hospital admissions, 3,4 recent authors have suggested an increasing rate of PLA, conditionally attributed to improved overall survival of immuno- compromised patient. 4 Continuous improvement in diagnosis and treatment has greatly decreased the mortality from as high as 80% before 1965 to 16% to 48% in the 1970s, 3,4 while a recent series suggested 15%. 4
The patients at risk include those with impaired host defenses, chronic granulomatous disease and leukemia are commonly noted. 4-6
Clinical manifestation of PLA in children are nonspecific. 3-6 Diagnosis of PLA is generally made by way of a high index of clinical suspicion in conjunction with appropriate imaging techniques. 4
The purpose of this paper is to report a rare case of pyogenic liver abscess due to Enterobacter aerogenes in a three- year old boy.
Case KM, a three-year-old Balinese boy was admitted to the Department of Child Health, Sanglah Hospital on February 13, 2002 with main complaint of the right-upper abdominal distension. The complaints first appeared about two weeks before admission. On the admission the right-upper quadrant of abdominal distension became more severe, and there were abdominal pain and redness on the right hipocondrium. Since one and a half months before admission, fever and abdominal pain had appeared. Loss of appetite began since two weeks before. Three days before admission, he had vomiting. There were no cough, jaundice, and abnormalities of bowel habits nor urination noted. Prenatal and labour history was uneventful. No history of abdominal surgery or trauma was found. CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 457 On physical examination, he was alert with a pulse rate of 120/minute, respiration rate 24/minute, and rectal temperature was 38 0 C. His body weight was 13,5 kg (25 th percentile). Conjunctive was pale but no jaundice on sclera. There was no enlargement of the cervical, axial or inguinal lymph nodes. The physical examination of the chest revealed symmetrical thorax with no retraction. There were no crackles nor wheezing heard. The heart sound was within normal limit. On palpation there was enlargement of the right-upper quadrant of abdomen with hyperaemia and pain. Hepatomegaly was also revealed. The spleen was not palpable. The bowel sound was normal on all quadrants. On percussion, shifting dullness was negative. The palms of the hands and feet were pale, without cyanosis. Laboratory examination showed white blood cell count 21,500/L, neutrophil 15,000//L, haemoglobin concentration 8.5 g/dl, haematocrite 25.2%, platelet count 586,000/L, erythrocyte sedimentation rate 150 mm/hr. Blood smear: erythrocyte normochromic-normocyter. Liver function test revealed: SGOT 26 IU/L, SGPT 8 IU/L, total bilirubin 0.52 mg/dl, direct bilirubin 0.16 mg/dl, alkaline phosphatase 390 IU/L, total protein 6.65 g/dl, albumin 2,97 g/dl. Stool examination showed on macroscopy: blood negative; on microscopic: white blood cell, erythrocyte and amoeba negative. The abdominal radiographs showed elevated right hemidiaphragm. There were not revealed radiopaque stone, calcification and mass with real border. The ileus sign was not found. The liver ultrasonography revealed enlargement of the liver; echoparenchyme was normal. There was a solid mass within the liver parenchyme. The margin of mass was clear and hypoechoic area around it was found. Size of the round mass was approximately 67 X 66 mm. The gall bladder was difficult to be evaluated. The conclusion of liver ultrasonography was hepatomegaly and intrahepatic mass with the first differential diagnosis of carcinoma hepatocellular and the second differential diagnosis of liver abscess. The history, physical examination, abdominal X-ray, and liver ultrasonography suggested working diagnosis of pyogenic liver abscess with CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 458 differential diagnosis of amoebic liver abscess and anaemia normochromic- normocyter. The patient was given intravenous Amicillin 500 mg three times a day. Intravenous metronidazole 200 mg divided three times a day. He was referred to The Paediatric Surgery Department and was diagnosed as a liver abscess with anaemia and so open surgical drainage was planned. Intravenous Cefotaxime 500 mg three times a day was given. Three days later open surgical drainage was done. There was pus on the right lobe of liver, 200 ml yellow pus emerged 200 ml. After the open surgical drainage, haemoglobin concentration decreased (6,6 g/dl), and then blood transfusion was administered. Haemoglobin concentration after transfusion increased (9,5 g/dl). Pus gram stain revealed gram- negative bacilli bacteria and leukocyte 1- 9/large field. Five days after open surgical drainage, the result of pus culture- resistance emerged as Enterobacter aerogenes that is sensitive to Ampicillin- sulbactam (16), Aztreonam (30), Cefotaxime (30), Ceftazidime (26), Ceftriaxone (28), Cefuroxime (20), Cephalexin (32), Chloramphenicol (30), Erythromycin (26), Gentamycin (28), Imipenem (22), Kanamycin (22). Cytology of pus showed acellular specimen with amorph only. The malignant cell was not found. The amoeba serology was negative. On serial stool examination, amoeba was found negative. Then diagnosis pyogenic liver abscess was made. Medicament therapy was given for 7 days with intravenous cefotaxime followed by oral sefradine for 7 days. Metronidazole was stopped. The following day after the abscess drainage, the result of laboratory examination returned to normal. White blood cell count 15,300/L, haemoglobin concentration 9.62 g/dl, haematocrite 27.7%, platelet count 726,000/L, erythrocyte sedimentation rate 58 mm/hr. Liver function test revealed: SGOT 36 IU/L, SGPT 16 IU/L, total bilirubin 0.32 mg/dl, direct bilirubin 0.04 mg/dl, alkaline phosphatase 173 IU/L. After an uneventful post abscess drainage recovery, the child was discharged from hospital in good condition. CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 459 Discussion Pyogenic liver abscess is a disease of middle-aged and older people 7 both sexes are affected about equally. 7
Geographic variation in disease frequency are not obvious, and there is no racial susceptibility. 7 Our patient is a rare case, because he was three years old. Clinical manifestations of PLA in Children commonly include malaise, anorexia, nausea, vomiting, and loss of weight. 3,7 Fever, abdominal pain, right- upper quadrant tenderness, and hepatomegaly are common sign. 4,6
J aundice is uncommon. 6 In our case, the patient had similar symptom and sign including anorexia, vomit, fever, abdominal pain, right-upper quadrant distension, and hepatomegaly. J aundice was not present. Routine laboratory study, like clinical presentation, is not specific for liver abscess and generally reflects any underlying disease of the patient. 3,5,8
White blood count is generally elevated with an increased proportion of polymorphonuclear neutrofil. 1,5
Although there is no comparable paediatric figure available, anaemia is found in 50% and elevated sedimentation rate in 90% of adult patients. 3,6 Liver function test revealed elevated bilirubin and alkaline phosphatase in the presence of biliary obstruction. 1,3,5,7 Transaminases are usually mildly elevated 3,5,7 and may be in normal range. 3 Albumin levels reflect disease severity, and levels below 2 g/dl carry a poor prognosis. 7 In our case, Laboratory examination showed white blood cell count was elevated with neutrophilia, haemoglobin concentration less than normal, erythrocyte sedimentation rate was high. Liver function test revealed serum transaminases were normal, bilirubin was normal, alkaline phosphatase was high, albumin was no less than 2 g/dl. Chest radiographs were found to be abnormal in more than 50% of adults with liver abscess, with findings including right-side atelectasis, infiltrates, pleural effusion, and elevation of the right hemidiaphragm 5,6,7 If infection is with gas-forming organisms, air-fluid level may be seen below the diaphragm on chest or abdominal film. 5,7
In our patient, the abdominal radiographs showed elevated right hemidiaphragm, but pleural effusion was not found. We could not see air-fluid CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 460 level because we did not do postero- anterior chest radiographs. Ultrasonography showed pyogenic liver abscess as round, ovoid, or elliptic lesions within the liver parenchyme, most often not contiguous with the liver capsule. The margin of each lesion is irregular and echo-poor. Abscesses are mostly hypoechoic compared with normal liver parenchyme, which contained a variable number of internal echoes. A hyperechoic appearance is occasionally seen, particularly when gas- forming organisms are present. 7
Pyogenic liver abscess is usually found in the right hepatic lobe, 7,9 and mostly solitary liver abscess(77,8%). 10 In our case, the liver ultrasonography revealed the enlagement of the liver; echoparenchyme was normal. There was a solid mass within the right liver parenchyme. The margin of mass was clear and hypoechoic area around it was found. Size of the round mass was approximately 67 X 66 mm. The gall bladder was difficult to evaluate. The conclusion of liver ultrasonography was hepatomegaly with mass intrahepatic. The first differential diagnosis of carcinoma hepatocellular and the second differential diagnosis of liver abscess were established. CT scanning is highly sensitive for diagnosis of intraabdominal abscess including liver abscess. 5,7 In liver the lesion appeared as areas of decreased attenuation. An advantage of CT scanning over ultrasonography is that the quality of the scan is not affected by bowel gas or foreign objects such as tubes and dressings. 7 In our case, CT scanning was not done. Blood cultures should be taken before the initiation of therapy. Although many authors quote 50% as the expected rate of positive culture, in some reports, the success rate has been almost 100%. 7
Paediatric patients with multiple abscesses are even more likely to have positive blood cultures than those with single abscesses. 3 If aspiration is performed, pus, not swabs, should be submitted to the laboratory, as promptly as possible. Aspirate pus is variably coloured, usually not dark brown or red- brown as is amoebic abscess content, and frequently is foul smelling. 7 Gram stain usually shows organisms unless there has been substantial preceding antibiotic treatment. The submitted material should be cultured for aerobic, CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 461 anaerobic, and microaerophilic organisms. 7
In our case, pus aspiration was not performed. We took the pus from open surgical drainage of abscess. The colour of pus was yellow with foul smelling. The result of the pus gram stain was gram-negative bacilli bacteria and leukocyte 1-9/large field. Blood culture was not done. The presence of a liver abscess may be suggested by the patients history, physical examination, results of laboratory test and is confirmed by imaging techniques. 7 In most cases, a confident diagnosis is reached combining epidemiological, clinical, and radiological features with the results of blood cultures and amoebic serology. 7
Negative amoebic serology virtually excludes the diagnosis of hepatic amoebiasis, despite rare cases in which serologic test becomes positive after the patients initial presentation. 7 In our patient, before the open surgical drainage, diagnosis of single liver abscess on the right liver was established. Differential diagnosis of pyogenic liver abscess were amoeba liver abscess, subphrenic abscess, malignancy of the liver, or acute cholecystitis. 1 In our patient, Cefotaxime and Metronidazole was given combined with open surgical drainage. The result of pus-culture Enterobacter aerogenes, indicated while amoebic serology was negative, and the diagnosis of pyogenic liver abscess was established. After that Metronidazole was stopped, the patient, was also given transfusions of blood after open surgical drainage. On the literature, the traditional treatment for pyogenic liver abscess has been open surgical drainage combined with broad- spectrum antibiotics. In recent time, percutaneous drainage has been applied to hepatic abscesses because it has more safety more safe and effective procedure. 7,11-13 Small abscess of less than 3-4 cm may be resolved with prolonged antibiotic therapy. 5
Pyogenic liver abscess may arise from (1) the portal circulation in patient with pyleplebitis or intra-abdominal sepsis (appedicitis, inflammatory bowel disease); (2) generalized sepsis; (3) cholangitis associated with biliary tract obstruction, such as gallstones, in inflammatory bowel disease, after a Kasai procedure, and with choledochal CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 462 bowel cyst; (4) Systemic spread from an intra-abdominal infection or contiguous spread (which usually produces large abscess); and (5) cryptogenic biliary tract infection. 3,6 Small abscesses (microabscesses) are most commonly secondary to bacteremia, or candidemia. 6
In our case, PLA was large abscess that may arise from systemic spread from an intra-abdominal. Most pyogenic liver abscesses are secondary to infection originating in the abdomen. 14 E. coli remains the single bacterium most frequently isolated in most reported series. 7 Other important aerobic organisms are various gram- negative bacilli, including species of Klebsiella, Proteus, and Pseudomonas, and gram-positive enteric organisms, such as Streptococcus faecalis and Streptococcus faecum. The latter two agents are referred to as enterococci. 5,7
The importance of anaerobic and microaerophilic organisms in liver abscess are a recent recognition. As many as one third to one half of patients may be infected with such organisms. Anaerobic organism incriminated include Bacteroides sp, Fusobacterium sp, anaerobic streptococci (Peptostreptococcus and Peptococcus spp), and rarely, Clostridium sp. Microaerophilic streptococci are considered by some authors as the most common of all organisms that cause liver abscess. Streptococcus milleri is the most important member of the group. 7
Unusual organisms documented as causing liver abscess on occasion includes species of Salmonella, Haemophilus, and Yersinia. Actinomycosis, tuberculosis, and melioidosis may also be associated with liver abscess. 5,7
Complications of PLA are rupture into the peritoneum or biliary system, septicaemic empyema, curiously endophthalmitis, 5 septicemias, metastatic abscess, direct extension, hypotension and shock, respiratory distress syndrome, mental obtundation, and renal failure. This complication was not found in our patient. Delay in diagnosis and treatment of pyogenic liver abscess has a major effect on outcome. 7,15 Reports of successful medical management, with or without aspiration, describe case-fatality rate as low as 10%. The prognosis is also related to underlying disease. 7 Mortality seems greater in patients with multiple abscesses. 7 Our patients prognosis is CASE REPORT J ournal of the Indonesian Medical Association J ima (4)1: April 2003. 463 good, because the cause of liver abscess is clear; single abscess, with albumin more than 2 g/dl, and diagnosis and treatment were performed early.
Summary A case of pyogenic liver abscess in a three-years-old Balinese boy has been reported. The diagnosis of pyogenic liver abscess was suspected by way of the patients history, physical examination, results of laboratory test, imaging techniques and confirmed by pus- culture. The single pyogenic liver abscess was in the right liver. The treatment of choice was open surgical drainage combined with antibiotic therapy. The prognosis of this patient was good.
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