Liver Abscess in a Child with Pyrexia of Unknown Origin: a Case Report

مجلة بابل الطبية- المجلد ال حادي عشر - العدد ال ول - Medical Journal of Babylon-Vol. 11 - No. 1 -201 4 201 4

Liver Abscess in a Child with Fever of Unknown Origin: A Case Report with Literature Review

Sharef Waadallah Sharef1* Ashraf Abdullah Saad1 Poovathoor Chacko Alexander1 1Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman. Corresponding Author: *Sharef Waadallah Sharef, MD, DCH, MRCPCH Department of Child Health, Sultan Qaboos University Hospital, P.O. Box 38, P.C 123, Al-Khodh, Sultanate of Oman.Telephone: (968) 9522814,1Fax: (968) 24141136 E-mail address: [email protected] Conflict of interest: The authors declare that they have no conflicts of interest or otherwise to report.

Case Report

Received 25 March 2013 Accepted 17 November 2013 Abstract Fever of unknown origin (FUO) with its long list of differential diagnosis including infections, neoplasms and collagen vascular diseases, remains a challenge to all clinicians. We report a case of an infant who presented with fever of one month duration with physical finding of hepatomegaly only. Extensive work up of laboratory and imaging investigations revealed a final diagnosis of liver abscess. Despite the existence of many developed diagnostic tools for such cases, good clinical judgment can lead to the definitive diagnosis saving the patients and their physicians from this dilemma. Although controversy exists on whether to treat liver abscess medically or by percutaneous or surgical drainage, our patient was treated with broad spectrum antibiotics for a total of 6 weeks duration and showed full resolution ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ـــ Introduction clinical practice in the tropics and ever of unknown origin (FUO) is subtropics especially in developing considered a diagnostic challenge. countries [2]. They continue to pose FIt is defined as temperature diagnostic and therapeutic challenges to greater than 38.3°C (101°F) on several physicians. Most of these abscesses are occasions, with more than 3 weeks' easily treatable but at the same time they duration of illness. Most cases are fatal if left untreated. Children have a caused by common problems including unique set of predisposing causes for Infections (40%) neoplasms (20%) and liver abscesses. The classical clinical collagen vascular diseases (15%) [1]. presentation is fever and abdominal pain, Liver abscesses are the most though, other symptoms including common type of visceral abscesses and nausea, vomiting, anorexia, weight loss, are frequently observed in pediatric and malaise can also occur.

252 مجلة بابل الطبية- المجلد ال حادي عشر - العدد ال ول - Medical Journal of Babylon-Vol. 11 - No. 1 -201 4 201 4

We report a case of an infant who g/L), his serum urea, creatinine, presented with fever of one month electrolytes, as well as liver enzymes, duration, which had been worked up and alkaline phosphatase were all within thoroughly as a case of Fever of the reference ranges. Chest X-ray was Unknown Origin where extensive unremarkable. Blood and urine cultures laboratory investigations led to a were send, and the infants was started on diagnostic dilemma and parental anxiety empirical antibiotic (intravenous but finally proved to be caused by liver ceftriaxone), after which, fever spikes abscess. The patient was then treated became less but continued to appear with broad spectrum antibiotics and intermittently. showed full resolution. Ultrasound of the abdomen revealed hypoechoic lesion in the right Case Presentation lobe of liver, measuring 49 x 27 mm in Eleven months old boy with size (Figure 1), with no increase in unremarkable perinatal history presented vascularity by Doppler study, suggestive to Accident & Emergency Department at of pyogenic liver abscess. Computed Sultan Qaboos University Hospital, tomography (CT) of the abdomen Oman, with persistent high grade fever showed contrast enhanced large of one month duration, during which he hypodense liver lesion at segments VI received 4 courses of co-amoxiclav and VII, measuring 50 x 43 x 48 mm in (amoxicillin and clavulanate). Systemic size (Figure 2). US guided aspiration and enquiry was negative, with no history of biopsy revealed necrotic tissue with neurological, respiratory, gastrointest- inflammatory cells mainly neutrophils. inal, genitourinary symptoms and no The family was informed for considering abnormalities at the joints. There was no percutaneous drainage of the abscess, history of travel or contact with animals but they refused. After prolonged and family history was unremarkable. counseling, they agreed to start IV Physical examination revealed a sick antibiotic alone. The infant showed good looking, febrile, pale, but well thriving clinical response. The biopsy infant, with all growth parameters on bacteriology showed light growth of 50th centile. There was hepatomegaly (3 staphylococcus aureus sensitive to cm below costal margin with liver span flucloxacillin and metronidazole. The of 10 cm), but no splenomegaly or antibiotics were adjusted accordingly lymphadenopathy. Other systemic and continued for total of 4 weeks. Work examination was normal. up for Immunodeficiency states He was admitted for further workup including HIV serology, and management. The initial immunoglobulins, neutrophil and investigations revealed microcytic complement function were all normal. hypochromic anemia with leucocytosis, The infant showed good clinical mainly neutrophilia. Peripheral blood response to treatment and became smear showed no blast cells. The afebrile and active. The inflammatory inflammatory markers were also markers have also improved gradually elevated (C-reactive protein CRP 152 (table 1). mg/L, and erythrocyte sedimentation Repeat abdominal US on day 10 rate ESR 98 mm/h). Apart from minimal showed significant reduction in size of hypoalbuminemia (serum albumin of 32 lesion (from 49 x 28 mm earlier, to 19 x

15 mm). Repeat US on day 21 showed diverticulitis, inflammatory bowel further reduction to 11 x 8 mm. After a disease, or through biliary route mainly month of hospital stay, the child was in adults, in conditions like extrahepatic discharged home in a good condition, biliary obstruction, choledocholithiasis, with oral cloxacillin for 2 more weeks. tumors, or postsurgical strictures [4]. Follow up abdominal US after 5 weeks Other co-morbid conditions associated showed complete resolution of the liver with the risk of PLA including liver abscess (Figure 3) transplantation, diabetes mellitus, and malignancy [7]. It has been documented Discussion that the majority of patients with PLA Thorough work up and investigation of were healthy. This might be attributed to FUO should be implemented according the high rate of environmental infection to the clinical presentation and physical in developing countries [8]. findings pointing towards one of the The clinical presentation of liver long listed differential diagnosis , as in abscess is insidious with many patients our patient who had only hepatomegally have symptoms for weeks prior to as a positive physical finding, that presentation. Fever and right upper helped in reaching the etiology of his quadrant pain are the most common fever. complaints. Fever occurs in 67-100% of Pyogenic liver abscess (PLA) is a patients and is usually associated with cause of significant morbidity and chills and malaise. Pain is reported in mortality with increasing frequency in 67-100% of patients and may be the developing world [3]. PLA has been associated with pleuritic chest pain or described to be rare in infancy and right shoulder pain [9]. Physical childhood, but it still remains a major examination findings might be normal in cause of high mortality in children [2]. as high as 38% of cases, however, right Untreated PLA remains uniformly fatal. upper quadrant tenderness, With timely administration of antibiotics hepatomegaly, liver mass, and jaundice and drainage procedures, the mortality are common findings [9]. occurs in 5-30% of cases. The most Increased serum alkaline common causes of death include sepsis, phosphatase activity and low albumin multi-organ failure, and hepatic failure concentration have been reported as the [4] The predisposing causes include most common abnormal laboratory parasitic infestations, skin infections, findings [10]. However, leukocytosis, protein calorie malnutrition, and trauma elevated levels of billirubin and [5]. Immune deficiency syndromes are aminotransferases are also common in important risk factors in children, such PLA [10]. Other laboratory findings as chronic granulomatous disease include anemia, leucocytosis, raised ESR (CGD), C1 complement deficiency and and C-reactive protein. hyper Immunoglobulin E syndrome [1]. For diagnosing PLA, abdominal Hematogenous spread occurs from ultrasonography is 80-100% sensitive. seeding of bacteria into the liver in cases The finding of a round or oval of systemic bacteremia from bacterial hypoechoic mass is usually consistent endocarditis or urinary sepsis [6]. with pyogenic abscess which was the Transmission may also occur through case in our patient. Other imaging the portal route as in appendicitis, modalities include MRI and CT

254 مجلة بابل الطبية- المجلد ال حادي عشر - العدد ال ول - Medical Journal of Babylon-Vol. 11 - No. 1 -201 4 201 4 scanning which have become the our decision of treatment with broad imaging studies of choice for detecting spectrum antibiotics intravenously that liver lesions. A hypodense lesion with resulted in complete resolution of the low attenuation areas and an enhancing abscess. rim is a classical CT scan image [11]. Also, in PLA the blood cultures are Conclusion positive in roughly 50% of cases and FUO in children is considered to culture of abscess fluid should be the be a diagnostic challenge. Thourough goal in establishing microbiologic history and clinical examination can lead diagnosis [12]. to the definitive diagnosis and save the Most liver abscesses in children patients and their physicians from this are pyogenic that is usually dilemma. Visceral abscesses are to be polymicrobial with Staphylococcus is considered as a possible differential the most commonly encountered diagnosis, among which, liver abscess is organism. Other organisms include the most common. Although there is no anaerobes, streptococci, klebsiella, definite consensus about the tuberculosis, and candida species. management of liver abscesses, medical Amoebic abscesses are less common treatment with prolonged broad constituting 21-30% of all cases of liver spectrum antibiotics is an acceptable abscesses and should be considered as a option. cause of primary liver abscess [13]. A significant reduction in the References mortality has occurred for all PLA since 1. M.P. Sharma and Arvind Kumar. 1950, possibly related to the advent of Liver abscess in children. percutaneous drainage and the use of Symposium on Hepatology and broad spectrum antibiotics [14]. There is Gastroenterolgy- II, Indian no definite consensus about the Journal of Pediatrics, Volume management of liver abscesses. 73- September, 2006. Although some authors have emphasized 2. Chen SC, Huang CC, Tsai SJ, et the importance of percutaneous and al. Severity of disease as main surgical drainage of pyogenic abscess predictor for mortality in patients [15]; others recommended drainage with pyogenic liver abscess. Am when the abscess is large or seems to J Surg. Aug 2009;198(2):164-72. rupture on US examination, or not 3. Seeto RK, Rockey DC. Pyogenic responding to antibiotic therapy after 72 liver abscess. Changes in h, or if the patient is septicemic [16]. A etiology, management, and course of six weeks antibiotic therapy outcome. Medicine (Baltimore). alone, including two weeks Mar 1996;75(2):99-113. intravenously, followed by four weeks 4. Rintoul R, O'Riordain MG, orally is recommended by some authors, Laurenson IF, et al. Changing especially when multiple or small management of pyogenic liver abscesses exist [15]. In our case, the abscess. Br J Surg. Sep decision not to drain the abscess was 1996;83(9):1215-8. based on parental refusal of the 5. Kaplan, GG, Gregson, DB, procedure. However, the dramatic Laupland, KB. Population-based response to antibiotics was supportive to study of the epidemiology of and

the risk factors for pyogenic liver clinical profile, microbiological abscess. Clin Gastroenterol characteristics, and management Hepatol 2004; 2:1032. in a Hong Kong hospital. J 6. Giorgio A, de Stefano G, Di Microbiol Immunol Infect 2008; Sarno A, et al. Percutaneous 41:483. needle aspiration of multiple 11. Lederman ER, Crum NF: pyogenic abscesses of the liver: Pyogenic liver abscess with a 13-year single-center experience. focus on Klebsiella pneumoniae AJR Am J Roentgenol. Dec as a primary pathogen: an 2006;187(6):1585-90. emerging disease with unique 7. Israeli R, Jule JR, Hom J. clinical characteristics. Am J Pediatric pyogenic liver abscess. Gastroenterol 2005, 100:322- Pediatric Emergency Care. 331. 2009;25:107–8. 12. Cheng HP, Siu LK, Chang FY: 8. Benedetti NJ, Desser TS, Jeffrey Extended-spectrum RB. Imaging of hepatic cephalosporin compared to infections. Ultrasound Q. Dec cefazolin for treatment of 2008;24(4):267-78. Klebsiella pneumoniae-caused 9. Muorah M, Hinds R, Verma A, liver abscess. Antimicrob Agents Yu D, Samyn M, Mieli-Vergani Chemother 2003, 47:2088-2092. G, et al. Liver abscesses in 13. Bari S, Sheikh KA, Malik AA, children: A single center Wani RA, Naqash SH. experience in the developed Percutaneous aspiration versus world. J Pediatr Gastroenterol open drainage of liver abscess in Nutr. 2006;42:201–6. children. Pediatr Surg Int. 10. Lok, KH, Li, KF, Li, KK, Szeto, 2007;23:69–74. ML. Pyogenic liver abscess:

Table 1 Result of inflammatory markers during the course of admission.

Day of admission D2 D8 D16 D30 WBC (X109/L) 18.4 7.3 13.4 5.4 CRP (mg/L) 152 84 9 3 ESR (mm/hr) 98 114 47 NA

Figure 1 Ultrasound abdomen showing the liver lesion (black arrow) at the level of segment 7. It is hyper-echoic in the centre and hypo-echoic at the periphery. It measures 4.9 x 2.7 cm in size.

Figure 2 Contrast enhanced CT scan of the liver (A: cross section. B: sagital section) showing hepatomegally with large hypodense lesion seen at segments VI and VII, measuring 50 x 43 x 48 mm in size. This lesion shows contrast enhancement within the lesion and there is perilesional enhancement.

Figure 3 Post treatment Ultrasound Showing total resolution of the liver lesion.