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| Case of the Week Tuesday 12/12/2006 |
Presented by Dr. Hend Ibrahim Shousha.
Pyogenic Liver Abscess
Click here to download a power point presentation for the case.
Staff Round Presentation
Unit members
Prof. Dr. Nabil El Kady.
Prof. Dr. Iman Ramzy.
Assistant prof. Dr.Wahid Doss.
Dr. Iman Hamza.
Dr. Dalia Omran.
Dr. Amr Abdl bary.
Dr. Tamer Elbaz.
Dr. Tamer Ismail.
Dr. Hossam Elgebaly.
Resident Mohammad Mohey El Din.
Resident Hend Ibrahim Shousha.
Personal history
A male patient, M.M.Z, 17 years old, student, single, born and lives in helwan.
No history of contact with canal water or receiving antischistosomal treatment.
No special habits of medical importance.
Complaint
Recurrent fever and pain in the right upper abdomen of 2 years duration.
Present History
The patient was admitted to fever hospital for 17 days where he received treatment in the form of parenteral fluids
and antibiotics with partial improvement of his symptoms.
He was referred to our unit where abdominal
ultrasonography was performed and revealed multiple
liver abscesses.
Ultrasound guided aspiration was performed together with IV
fluids and antibiotics till complete remission of the abscesses
and the patient was discharged.
His liver abscesses recurred 4 times within the past 2 years with
the same clinical Presentation and hospital admission.
His last attack was 2 months ago but the patient was clinically
more deteriorated and developed jaundice without change in the
color of urine or stools, pruritus, perception of body masses or
bleeding from any body orifices.
No history of other system affection.
Past history No past history of operations.
No history of DM or HTN.
No history of prolonged drug intake.
Family history
No similar conditions.
Negative consanguinity.
General examination
On admission: The patient was:
Toxic.
Underweight ( 45 Kg).
Bl.p:90/60. pulse:120/min.
Temperature: 39 c, continuous
Head and neck examination
Eyes: tinge of jaundice.
Pallor.
Acne vulgaris with pustules and scars.
3-4small(<1cm) discrete non tender freely mobile submandibular L.Ns on both sides.
No thyroid swelling.
Neck veins are not congested.
Upper limb examination:
No lymph node swellings.
No clubbing.
Lower limb examination:
Small scars of previous pyogenic abscesses at both inguinal regions and the buttocks.
No lower limb oedema.
Intact pulsations.
Abdominal examination Scaphoid abdomen with preserved waist.
Acute subcostal angle.
No divarication of recti.
No visible veins, scars, hernias or abnormal pigmentation.
Liver:
Upper border:
5th Intercostal space Rt MCL.
Lower border:
right lobe: 5cm below the costal margin
left lobe: 10cm below the xiphisternum
smooth surface, soft in consistency, Tender, not pulsating.
Spleen:
Not felt.
resonant Traub`s area.
No ascites.
Auscultation:
Normal intestinal sounds.
No venous hum.
CVS , Chest and CNS examination
Free
Lab. investigations
Urinalysis:
Free.
Stool analysis:
Some entamoeba histolytica cysts.
Repeated Stool cultures:
normal GIT flora.
Z-N stain in stools:
negative for acid fast bacilli.
CBC (on admission)
HGB 7.0g/dl (12-18) WBC 9.2 x 1000/ul
MCV 70.6fl (80-99) B 0%
MCH 23.0 pg (27-31) E 1%
MCHC 32.5g/dl (33-37) ST 5%
Seg 66%
L 17%
M 9%
PLT 531x1000 / ul
ESR 1st hour : 140 2nd hour : 150
Marked microcytic hypochromic anemia.
RBCs show anisopoikilocytosis.
Neutrophils show shift to the left.
Mild thrombocytosis.
CBC : (2 months later)
HGB 12.1g/dl (12-18) WBC 6.9 x 1000/ul
MCV 74.6fl (80-99) B 0%
MCH 25.0 pg (27-31) E 3%
MCHC 34.5g/dl (33-37) ST 4%
Seg 32%
L 53%
M 8%
PLT 454x1000 / ul
ESR 1st hour : 100 2nd hour : 135
Serum iron: 33ug/dl.
TIBC: 237ug/dl.
Liver Biochemical profile
PT: 14.9 sec .
PC: 80%.
INR: 1.18.
Kidney functions:
Creatinine 0.6 mg/dl.
Urea 23mg/dl.
Serum electrolytes:
Na 137 mmol/l.
K 4.6 mmol/l.
Blood sugar:
FBS 85 mg/dl.
PPBS 112 mg/dl.
Hepatitis markers
HBs Ag : negative.
HBs Ab : negative.
HBc Ab total : negative.
HCV Ab : negative.
HAV Ab total & IgM : negative.
HIV Ab :negative.
Abdominal ultrasonography
Liver: both lobes are enlarged with multiple hypo echoic focal lesions with posterior enhancement involving both lobes ranging from 3-6 cm in diameter. Portal vein, hepatic veins are normal. IHBR are not dilated.
Gall bladder: average in size and wall thickness, no stones or mud inside. CBD is not dilated.
Spleen: not enlarged, homogenous echo pattern.
Pancreas and midline structures: are free .
No ascites.
Conclusion:
Multiple hypo echoic focal lesions, picture
highly suggestive of pyogenic liver abscesses.
Microbiological exam. Of abscess specimen
Gram stain: many pus cells and no organism could be seen.
Culture: Aerobic: Staphylococcus aureus.
Sensitivity: sensitive to:
Amikacin.
Amoxicillin-clavulinic acid.
Cefotaxime.
Cefoperazone.
Clindamycin.
Cetriaxone.
Chloramphenicol.
Erythromycin.
Gentamycin.
Ofloxacin.
Tavanic .
Maxipime.
Microbiological exam. Of abscess specimen:
Z-N stain:
no acid fast bacilli could be seen.
Chest X-ray report
Markedly elevated right diaphragmatic copula with right basal atelectatic bands, blunt right costophrenic angle and lamellar effusion.
Unremarkable left lung and costophrenic angle.
Cardiac size could not be assessed. obliterated cardiac waist(? Of significance).
Being On:
High protein diet.
Iv fluids.
Iv antibiotics( claforan and metronidazole) for 2 weeks. Then ofloxacin for another 2 weeks.
Follow up abdominal ultrasonography and ultrasound guided aspiration every week from the abscesses.
Oral iron supplements.
The general condition and lab. results of the patient was dramatically improved.
1 month later the patient developed subphrenic collection of serosanguinous fluid for which a pigtail tube was inserted follow up irrigation and aspiration were performed.
The aim of our next investigations was to find a reasonable cause for abscess recurrence, so we investigated:
Possible source of a septic focus.
The Immunologic status of the patient .
Anti fasciola Ab (IHA):
1/320 titer (significant reaction)
Triclabendazole 10mglkg two doses.
Titre dropped to: 1/160.
Serology for amoebiasis:
less than 1/80( non significant )
Anti hydatid Ab:
negative
Widal test:
S.Typhi (O) negative
S.Typhi (H) negative
S.Paratyphi-A(H) negative
S.Paratyphi-B(H) negative
Brucella test:
B.Abortus negative
B.Melitensis negative
Echocardiography
Normal chambers dimensions and function.
Normal valves.
No intracardiac mases or thrombi.
Normal pericardial thickness.
mild to moderate degree of anterior pericardial effusion with no echocardiographic evidence suggestive of increased intrapericardial pressure at present.
Conclusion:
Mild to moderate degree of pericardial effusion, otherwise, within normal Echo/doppler study
ERCP report
Conclusion:
duodenoscopy revealed normal papilla
Cannulation and cholangiogram revealed normal CBD and IHBRs
Colonoscopy
Colonoscopic examination was done up to the cecum and revealed hyperemic rectal mucosa with small linear ulcerations.
Multiple biopsies were taken, no other mucosal abnormalities were detected in the rest of the colon.
Pathology report
Diagnosis:
Colonoscopic biopsy : chronic nonspecific mildly active colitis.
Dental and ENT consultation
No septic focus.
Protein electrophoresis
There is mild hypoalbuminemia and hypergammaglobulinemia of polyclonal pattern with inverted A/G ratio.
IgG: 5130mg/dl
Normal Range 700-1600mg/dl
IgM: 408mg/dl
Normal Range 40-230mg/dl
Flow cytometry
Immunophenotypic analysis of peripheral blood mononuclear cells revealed the following:
Tuberculin test
negative
Neutrophil function test
Nitro Blue tetrazolium(NBT) :
59%
(N.chronic granulomatous disease <10%)
Phagocytosis:
98%
N:(60-100%)
Summary
Male patient 17 years old with:
Recurrent pyogenic liver abscess
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