Đề Xuất 5/2022 # Microbiology And Management Of Pediatric Liver Abscesses: Two Cases Caused By Streptococcus Anginosus Group # Top Like

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  • Pyogenic liver abscesses in the pediatric population are rare occurrences in the developed world. We psent two cases of pviously healthy males psenting with fever and abdominal pain found to have liver abscesses due to organisms in the Streptococcus anginosus group. The microbiology of S. anginosus along with the management and recommended treatment in children with liver abscesses is discussed.

    1. Case 1

    DK is a 16-year-old male psenting with severe abdominal pain. Three days prior while playing baseball, DK slid and began complaining of chest pain. Three days later he developed fever to 102°F and chills. His vital signs on psentation were blood pssure 102/71, pulse 108 bpm, respirations 16 bpm, and temperature 39.2°C. He was awake, tired, and flushed appearing. He had pain along his ribs on the lower right side of his abdomen along with decreased bowel sounds and tenderness of the right upper quadrant with voluntary guarding. There was no hepatosplenomegaly or masses. Labs included a disseminated intravascular coagulation (DIC) profile which showed fibrinogen 766 and a CBC showing WBC 13.6, HgB 12.7, Hct 35, platelets of 386 with 76% neutrophils, 15% lymphocytes, and 8% monocytes. Liver function testing was normal. He had a negative monospot, a normal amylase and lipase, an erythrocyte sedimentation rate (ESR) of 97 mm/hr, and a c-reactive protein (CRP) of 37.1 mg/dL. An ultrasound of the abdomen revealed a hypoechoic mass within the anterolateral right hepatic lobe further delineated by CT (Figure 1(a)) which revealed an abscess. He was placed on intravenous Piperacillin/Tazobactam followed by percutaneous drainage. Culture revealed 2+ Streptococcus intermedius (viridians strep). DK had serial CRPs which improved. A repeat ultrasound showed no lesion and the drain was removed. He was discharged home on intravenous Clindamycin; however, five days later he became febrile and returned to the emergency room. He had a WBC 17.7 with 85% neutrophils, a mild transaminitis, and a CRP of 5.8 mg/dL. An ultrasound of his abdomen revealed  cm fluid collection. He was taken to interventional radiology for repeat aspiration and replacement of drain. A follow-up ultrasound showed a persistent hypoechoic area adjacent to the drain consistent with hematoma so the drain was capped. Repeat ultrasound remained unchanged and the drain was removed. Inflammatory markers continued to decline and he was discharged home on intravenous ampicillin.

    2. Case 2

    MM is a 14-year-old male with cold symptoms four days prior to psentation followed by the onset of several episodes of emesis and diarrhea along with decreased appetite and fever to 105.4°F. His vital signs were blood pssure 99/47 mmHg, pulse 137, respirations 18, and temperature 39.5°C. He was well appearing with dry mucus membranes. His abdominal exam was benign without hepatosplenomegaly or masses. Labs were drawn, that showed a WBC 4.1, a hemoglobin 10.7 g/dL, platelets 109 K/uL, AST 95 U/L, ALT 93 U/L, albumin 2.7 g/dL, total and direct bilirubin 2.6 mg/dL and 0.6 mg/dL, respectively, PT 13.8 sec, and fibrinogen 744 mg/dL. During admission MM began complaining of RUQ abdominal pain and an ultrasound showed a 6 cm mass in the liver along with a thickened gallbladder wall. A CT of the abdomen was completed (Figure 1(b)) and a liver biopsy was performed with 3 mLs of purulent fluid drained. MM’s blood culture and abscess culture revealed Streptococcus consellatus and he was started on intravenous Piperacillin/Tazobactam. A repeat ultrasound was performed five days later which showed interval increased size and cystic component of the liver abscess. He underwent repeat drainage and percutaneous drain placement. He had significant improvement and ultrasounds showed interval decrease in size and cystic components of the complex liver abscess. The drain was capped and a subsequent ultrasound revealed an interval decrease in size. The drain was then removed and he was discharged home on intravenous ceftriaxone.

    3. Discussion

    Most descriptions of pyogenic liver abscesses (PLA) have been in the adult literature. These abscesses tend to be polymicrobial and typically are associated with cholangitis. PLA are a rare occurrence in infants and children, with an incidence of 0.007% to 0.04% of all hospital admissions per year. When left untreated, mortality rates of 80%-100% have been seen . The clinical features of features of PLA are nonspecific: fever (89.6%), chills (69%), and abdominal pain (72.2%). However, only about 30% of patients psent with all three symptoms . Laboratory abnormalities include a leukocytosis (84% of patients), anemia (88.9% of patients), hypoalbuminemia (94% of patients), and an elevated alkaline phosphatase (73% of patients). An elevated CRP is commonly seen as well . The S. anginosus group has a tendency to form abscess; however, the reasons are not completely understood. The group has been shown to possess intrinsic factors that are likely to be involved in their pathogenesis such as adhesins on their cell surfaces that facilitate adherence to cell walls and allow pathogens to attach to the sites of tissue damage . These organisms tend to be sensitive to penicillin as was the case with both of our patients.

    The early recognition of PLA is important. Abdominal ultrasound is the imaging modality of choice as it is diagnostic in over 90% of cases . Half of patients who undergo aspiration may need repeat aspiration when no indwelling drain is placed. This may need to be done up to three times . In patients that fail this approach after 72 hours percutaneous drain placement is typically attempted under CT or sonographic guidance. Routine flushing of the drains is performed. Drains are left in place until the drainage is minimal. Risk factors for failed initial nonoperative management include multiloculated abscesses, biliary communication, increased serum urea and creatinine, or increased serum bilirubin . Previously, laparotomy was also used in patients with multiple abscesses or those with biliary communication. Newer literature suggests that percutaneous drain placement is typically successful even in those with multiloculated abscesses, with multiple abscesses, or with biliary communication without obstruction and can be attempted in place of initial laparotomy . Antibiotic choices can be tailored once an organism is identified and susceptibilities are available. In immunocompromised patients, especially those with CGD, it is not unreasonable to add antifungal coverage . Resolution on imaging typically lags behind clinical and laboratory improvement as some studies suggest sonographic evidence can persist for an average of 14 weeks and up to 2 years [ 10].

    Disclosure

    M. Cellucci, E. Simon, and S. Eppes have no relevant financial disclosures to report.

    References

    1. R. Salahi, S. Dehghani, H. Salahi et al., “Liver abscess in children: a 10-year single centre experience,” View at: The Saudi Journal of Gastroenterology, vol. 17, pp. 199-202, 2011. Google Scholar
    2. Y. Mirzanejad and C. Stratton, “Mandell, douglas and bennett’s,” in View at: Principles and Practices of Infectious Disease, pp. 2451-2457, 6th edition, 2005. Google Scholar
    3. B. English and J. Shenep, “Enterococcal and viridans streptococcal infections,” in View at: Feigin and Cherry’S Textbook of Pediatric Infectious Disease, pp. 1276-1288, 6th edition, 2009. Google Scholar
    4. S. Ch Yu, R. Hg Lo, P. S. Kan, and C. Metreweli, “Pyogenic liver abscess: treatment with needle aspiration,” View at: Clinical Radiology, vol. 52, no. 12, pp. 912-916, 1997. Google Scholar

    Copyright © 2012 Michael Cellucci et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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