Fungal Infections of the Liver William St. Clair Symmers*

10:373 Address to the Japanese Society of Hepatology (Tokyo, 13th March, 1969) Fungal Infections of the Liver William St. Clair Symmers* Summary Fungal infections of the liver rarely cause specific clinical manif estations. This is because the development of hepatic lesions is, in most cases, merely an incident in the courseof a progressive haematogenous systemic mycosis, the clinical picturebeing dominated by the general effects of the septicaemic infection. In most of these cases the fungal septicaemia is itself secondary to someunderlying disease that has predisposed to invasion of the body by the fungi, which in such circumstances commonly belong to the numerous group of so-called 'opportunistic' organisms. For the same reason, fungal infections involving only the liver are exceptionally rare. Such may result from a penetrating injury by some article contaminated by fungi: an illustrative case is described. An occasional case of actinomycosis of the liver in the absence of any recognized actinomycotic focus elsewhere in the body may reflect an observational error(e. g., the overlooking of a small intestinal focus in a case here recorded); alternatively, the initial focus may have healed. Clinically or pathologically obtrusive hepatic mycosis may be secondary to recognized infection elsewhere in the body. The direct extension of actinomycosis from an infected lung through the diaphragm into the liver is an instance of how this may occur. Likewise, fungal infection may spread by the portal blood stream from a primary focus of disease in the alimentary tract: actinomycosis, again, is the most frequent example of this event, but comparable cases of hepatic candidosis and hepatic geotrichosis are included in the paper. A particular manifestation of hepatic mycosis is the occurrence of hepatic failure or hepatorenal failure from widespread infarction of the liver or of the liver and kidneys, the result of vasothrombosis due to invasion by phycomycetes, at least some of which provoke extensive thrombosis in the course of their haematogenous dissemination. What is known of the aetiology and pathogenesis of fungal infections of the liver indicates that the principles of diagnosis and treatment are no different from those relating tofungal infections of other parts of the body. liver may become infected by micro-organisms: portal Introduction vein, hepatic artery, common bile duct,lymphatics, Theoretically, there are six routes by which the direct extension from an infected adjoining structure , and penetrating wounds. In fact, as far as fungal * Professor of Histopathology in the University of infections are concerned, only the portal vein and he- London and Consultant Pathologist to the Charing Cross Group of Hospitals, London. patic artery are of practical importance. I know of 10:374 肝臓10巻5号(1969) no record of mycotic infection of the liver taking place tenderness of the liver. The cause of these symp- by the biliary or lymphatic routes. Direct extension toms remained uncertain until the development into the liver of a mycotic infection in a contiguous of sinuses discharging through the skin of the structure must be very infrequent: two instances are right hypochondrium: Actinomycesisraelii was demon- summarized below. Again, I know of no reported strated in the exudate. This was before the days case of fungal infection resulting from a penetrating of penicillin and the patient eventually died of wound of the liver: a possibly unique case of infection the effects of the long-standing infection. by this means is recorded here for the first time. Necropsy showed very extensive actinomycosis The case reports that follow illustrate these various of the liver and overlying tissues. A particularly pathways of infection of the liver by fungi. thorough search did not reveal any evidence of the infection in any other parts of the body, the A) Hepatic Mycosis Resulting from Infection rest of the abdomen and the lungs and the mouth by Way of the Portal Vein and throat being specially carefully examined. Comment. When, as in such a case as this, When a fungal infection of the liver results from hepatic infection is the sole discovered manifestation dissemination of the causative organism in the portal of actinomycosis, there are two possible explanations. blood stream it may ordinarily be assumed that the First, the initial actinomycotic focus may have source of the infection is intestinal. The intestinal been so insignificant that it escaped notice at nec- infection may be a primary mycosis, particularly ac- ropsy. Second, it is conceivable that the initial tinomycosis, or a mycosis complicating a pre-existing focus healed without detectable trace, the secondary lesion, e. g., infection of an ulcerated carcinoma or foci of infection in the liver persisting and advancing. comparable condition by Candida species or Geotrichum Case2: Fatal Hepatic ActinomycosisSecondary to candidum. It is also possible that moulds, such as a Small Focus in the Ileocaecal Region That Almost Aspergillus species and the various phycomycetes, might Escaped Detection. An elderly man died of cachexia also enter the body through intestinal ulcers and then complicating extensive and long-standing ac- reach the liver in the portal blood, but as far as I know tinomycosis of the liver. His case seemed in general this has not as yet been observed. somewhat similar to Case 1 (above), for the post- mortem examination at first did not reveal any i) Actinomycosis* evidence of actinomycotic lesions outside the liver Actinomycosis remains by far the least infrequent and the overlying tissues of the abdominal and fungal infection of the liver. Its occurrence in this chest wall. However, more detailed dissection organ is usually due to spread from an intestinal focus of the intestinal tract disclosed a firm mass in the by way of the portal vein. fatty tissue between the ileum and the caecum. Case 1: Fatal Hepatic Actinomycosis.without Recognized This mass, about 2 cm. across, consisted of scar ActinomycoticInfection Elsewherein the Body. A woman, tissue enclosing a series of small abscesses: histolo- aged 46, died of actinomycotic infection of the gical examination demonstrated typical colonies liver. During two years preceding her death of Actinomycesin the pus. she had a series of febrile illnesses accompanied Comment. The actinomycotic focus in the by slight jaundice and by some enlargement and ileocaecal angle may have been the source of the * In accordance with the practice endorsed by the hepatic disease, the infection spreading through Medical Mycology Committee of the British Medical the portal venous system. One can only speculate Research Council the actinomycetes are regarded for on the sequence of events that might explain this the purposes of this paper as fungi (Actinomyces species, Nocardia species, StrePtomyces species). unusual clinicopathological picture. Fungal Infections of the Liver 10:375 Hepatic Involvement, Following Fungal Colonization Staphylococcal Infections Can Be Mistaken (Possibly Chlortetracycline-Induced)of an Unsuspected for Actinoniycosis Colonic Carcinoma in a Patient under Treatment for Staphylococcal Hepatitis (Staphylococcal Bo- Myelomatosiswith CytotoxicDrugs. A man, aged 70, tryomycosis). The classic 'honeycomb' abscesses charac- had for many months been under treatment for teristic of actinomycosis of the liver are well known myelomatosis with cytotoxic drugs. He developed to generations of medical students and are tradition- an acute bacterial pneumonia: this responded to ally represented in most museums of pathological large doses of chlortetracycline. However, his anatomy. It is therefore important in practice to general condition deteriorated more rapidly as remember that staphylococcal hepatitis can simulate he recovered from the pneumonia, and his blood actinomycosis, both macroscopically and microscopically. was repeatedly found to grow Geotrichumcandidum Staphylococcal hepatitis is sometimes an outcome in pure culture. Amphotericin B at first seemed of suppurative pylephlebitis originating in local septic to control the fungal septicaemia, but this response thrombosis of the radicles of the portal vein in the was not sustained and he died. vicinity of an appendix abscess; in other cases it re- Necropsy showed several very large abscesses sults without any associated thrombosis at the point in the liver. The geotrichum was isolated in of entry of the infection, the staphylococci then pre- pure culture from these and from multiple miliary sumably gaining access directly to the circulating blood lesions in other organs. The source of the geo- to establish a portal pyaemia. The ramifying cavi- trichal infection was considered to be a clinically ties of the subacute or chronic abscesses that charac- unsuspected primary carcinoma of the caecum, terize staphylococcal hepatitis are considerably larger the ulcerated surface of which was heavily colo- and correspondingly less numerous than those of ac- nized by the fungus. The presence of widespread tinomycosis. skeletal myelomatosis was also confirmed. It is important to remember, in relation to Comment. Presumably, the chlortetracycline the histological diagnosis of hepatic actinomycosis had so altered the normal colonic flora that the (as of actinomycosis elsewhere in the body), that geotrichum proliferated freely and was able to the peculiar aggregates of staphylococci that are the infect the carcinomatous ulcer, thence gaining characteristic feature of the lesions of

Load more