Pyogenic Liver Abscess in Children-South Indian Experiences By Alok Kumar, S. Srinivasan, and A.K. Sharma

Pondicherry, India

Purpose: Eighteen cases of pyogenic liver abscess (PLA) admitted at JIPMER hospital, South India, over a &year period were analyzed to document the clinical profile and to evaluate the management of PLA among children.

Methods: Records of all these patients were reviewed for presenting signs and symptoms, any associated condition, investigative results, management, and follow-up findings.

Results: The overall incidence of PLA was 78.9 per 100,000 pediatric (under 12 years) admissions. One patient had aplastic anemia and was on long-term steroid therapy, whereas another had measles in recent past. Moderate to severe malnutrition was present in five (27.8%) and ascariasis in seven (38.9%) children. Common presentations were fever (100%). abdominal pain (7&g%), and tender hepatomegaly (83.3%). Ultrasonography results were positive in all cases. Fourteen patients (77.8%) had solitary liver abscess, and four had multiple abscesses. Organism was isolated in 11 cases (63.6%), and Staphylococcus aureus was the commonest isolate (66.7%). All patients received antibiotics. Twelve cases were managed conservatively with antibiotics alone, of these

only two (16.7%) required drainage later on. Percutaneous aspiration was also undertaken in four additional (22.2%) cases and open drainage in two (ll.l%), at presentation. The overall mortality rate was 11.1%. Time taken for complete resolution ranged from 10 days to 40 days.

Conclusions: Any child presenting with fever, abdominal pain, and tender hepatomegaly should be subjected to ultra- sound scan for early detection of PLA. S aureus is the commonest causative agent. Enterobacteriaceae contribute significantly during infancy. A combination of cloxacillin and gentamicin or a third generation cephalosporine and gentami- tin, especially in infants, is a satisfactory initial coverage. Therapeutic drainage is not a must in all cases of PLA. When required, percutaneous needle aspiration is safe and effec- tive. Resolution and significant reduction In mortality has been made possible by early detection and optimum antibiot- ics therapy. J Pediatr Surg 33:417-421. Copyright o 1998 by W.B. Saun- ders Company.

INDEX WORDS: Liver abscess, pyogenic.

P YOGENIC LIVER ABSCESS (PLA) in infancy and childhood has been described to be a rare problem,

but with high mortality.1-6 Majority of reported cases have occurred among immunocompromised children, especially those with chronic granulomatous disease.‘-4 Only a few cases have been reported among otherwise healthy children, most from developing countries other than South Africa.5-10 Prompted by our observation of a number of cases of PLA in otherwise healthy children, we were interested in reviewing all cases of PLA admitted in the pediatric wards of this hospital over the past 6 years. Our interest was further strengthened by the fact that the diagnosis, management, and outcome in PLA in adults has undergone much change over past few decades with significant reduction in morbidity and mortality.1i-13 How- ever, consensus regarding management of PLA among children is yet to emerge, and documentation on this subject is scanty.

MATERIALS AND METHODS

Eighteen patients were admitted m pediatric wards at JIPMER hospital, South India. between 1990 and 1996, with the diagnosis of PLA. Cases were mcluded m this retrospective study if (1) there were hypoechoic lessons in liver and (2) pus was aspirated from these lesions with negative amoebic serology and/or these lesions were cured after adequate antibiotic treatment, and/or isolation of bacterial organism

Journal ofPediatric Surgery, Vol33, No 3 (March), 1998: pp 417-421

from either pus or blood. For these cases all relevant data were reviewed.

Age, sex. symptoms and their duration. clinical signs at presentation. and any associated conditions were noted. Results of the diagnostic workups including ultrasound findings and organisms isolated, manage- ment including details of antibiotic therapy and drainage procedure were all recorded. Specific information was sought regarding presence of any underlying predisposing factors in all these patients at presenta- tion and during follow-up. Temporal profile of the symptoms and lesion as seen on repeated ultrasound examination during follow-up was also recorded

RESULTS

The overall incidence of PLA was 78.9 per 100,000 pediatric (under 12 years age) admissions. Details of the cases are shown in Table 1. Their age ranged between 3 months to 12 years, with a median age of 3 years. The overall male to female ratio was 1.6: 1. Among associated conditions. five children had moderate to severe protein energy malnutrition. One child had measles in the recent

From the Department of Paediatrics and Radiodzagnosis, Jawaharlal Institute of Post-Graduate Medical Education & Research, Pondi- cheny-605 006, Indzn.

Address reprint requests to S. Snnivasan. Head, Department oj Paediatrics, JIPMER, Pondiclzerry-605 006, India.

Copynght 0 1998 by WB. Samders Company 0022.3368/98/3303-0003$03.00/O

417

418 KUMAR, SRINIVASAN, AND SHARMA

Table 1. Details of Cases

case sex, Presenting Symp- Assoaated Location and Organisms Other Treatment

Follow-Up No. Age (yr) toms and Signs Conditions No of Abscess Isolated Investigations Antlbmtlcs Dramage and Outcome

1 M, 5 Fever, abdommal Multiple subcuta- pain, tender hepa- nexus pyemic tomegaly abscess

2 F, 3 Fever, swelling rt. NOW hypochondwm, abdommal pan, tender hepato- megaly

3 F, 7112 Fever, abdominal dis- Septxemia, PEM, tensjon, pedal postmeasle’s edema, hepato- state megaly

4 M.5 Fever, multiple tender Multiple subcuta- subcutaneous neous pyemlc swellmg, tender abscess hepatomegaly

5 6 3 Fever, abdommal dls- Pyopewardwm, tenslon &pain, pleural effusion, pedal edema, 1 JVP, PEM tender hepato- megaly

6 M,6 Fever, epigastnc pan None &swelling, tender hepatomegaly

7 M, I’/, Fever, abdominal dls- None tension, tender hepatomegaly

Right lobe, smgle, 4x5cm

Right lobe, smgle, 5x4cm

Both lobes, multIpIe, 2X2cm

Right lobe, smgle, 4x47cm

Right lobe, smgle, 4.4 x 6 7 cm

Left lobe, single, 3 6 x 3.6 cm

Right lobe, smgle, 8 6 x 6.4 cm

Pus, s auraus; Blood, sterile

Blood, ster- de; Pus, sterile

TLC: 22,000 DC: N48 E2 L50

cloxaClllln + NOW3 gentamwn

Resolution* -D20, afe- bnle -DlO

ampicillin + open Resolution gentamlcm + drainage -DlO, afe- metronldazole brrle -D5

ALT: 22 W/L AP: 240 IU/L TLC: 18,000 DC:N72E4L24

TLC: 18,000 DC: N30 L69 El PS-Sepsis

TLC, 9,600 DC: N58 El2 L30

Blood, E co/i Cloxaclllln + NOW gentamwn + metronld- az0le

Cloxaclllln + NOW gentamicin

Died -D3

Pus, s a”i-euS

Resolvmg -D30, afe- brile -D7

Resolvmg -D35, afe- brlle -DlO

Blood, S auraus; PUS, sterile

Pus, s a”R?US, Blood, sterile

Blood, S auraus; PUS, sterile

Blood, ster- 1le; Pus, sterile

Pus, sterile, Blood, sterile

Blood, sterile

TLC: 32,000 DC: N41 L59

Cloxacllln + NOM gentamxm

TLC: 22,000 DC: N53 E7 L40 ALT-50 IV/L AP-170 IV/L TLC: 45,000 DC: N57 L43 AP 4490 IU/L ALT 80 W/L TLC: 26000 DC: N78 E2 L20

TLC. 11900 DC: N24 El L75

Cloxacillln + None gentamicln

Resolution -D15, afe- brile - D3

Ampicillin + PerCUtane- gentamlcln + 0”s asp,- metronidazole ration

Cloxaclllin + NOM gentamwn

Resolution -030, afe- brile -DlO

Amplclllm + Percutane- gentamwn + 0”s aspi- metronidazole ration

Ampicillin + NOM gentamlcin

Resolution -D30, afe- brile -D7

Resolvmg -D13, afe- brlle -D5

Resolution -D30, efe- bnle -D5

Cloxaclllln + Percutane- Resolving gentamlcin + ous aspi- -D30, afe metromdazole ration brlle -D7

8 F, 5 Fever, tender hepato- megaly, pan abdomen

9 M,3 Fever, breathlessness hepalomegaly

10 M,12 Fever, dwrhea, abdommal tender- ness, hepato- megaly

11 M,2 Fever, breathless, dys- entery, tender hepatomegaly

Rt basal pneumon!tis Right lobe, single, 4x4cm

NOW Right lobe, smgle, 6.8 x 7.2 cm

Gastroenteritls, pneu- Right lobe. single, monitis, aplastic 3x3cm anem,a on stenxds

Gastroenteritis, pneu- Right lobe, single, monltis, PEM, 8x75cm hydrocephalus

TLC 6,800 DC. N20 L72 M8

Pus, sterile; Blood, sterile

TLC: 28,000 DC N80L20 AP-160 Ill/L ALT-40 W/L

12 M, 12 Abdominal pan, NOna Left lobe, single,4 X 4 Pus, S tender hepato- cm aureus; megaly Blood,

sterile 13 F,9 Fever, pan & NOW R!ght lobe, single, Pus &

swelling, right 10 % IOcm Blood, S hypochondrwm, auraus tender hepato- megaly

14 M,5 Fever, abdominal Collectton in subdr- Right lobe, smgle, Blood, pa,“, tender hepa- phragmatlc space, 2x4cm sterile tomegaly pneumonitis

15 M, 3% Fever, abdommal dw Peritomtls, PEM Right lobe, smgle, Blood, K tensmn, hepato- 3.5 x 3 6 cm p”e”- megaly monk,

PUS, sterile

16 M.8 Fever, abdommal Anemia with CCF Both lobes, multlple, Blood, pa,“, T JVP, pedal 1.5 x 1 cm sterile edema, tender hepatomegaly

17 M.5 Fever, pedal edema, Myocarditls with CCF, Right lobe, multiple, Blood, S tender hepato- septicemia lxlcm typhi megaly, abdominal pain

18 F,l Fever. diarrhea, hepa- Gastroenterltas, septl- Both lobes, multIpie, Blood, K tomegaly cemia, PEM 0.8 x 0.7 cm &We”-

moniae

TLC: 10,000 DC: N56 E4 L40 AP 250 W/L ALT 15 IUiL TLC: 11,000 DC. N48 E2 L50 AP 303 IU/L ALT 75 IUiL

Cloxaclllln + gentamicm

Ampiclllln changed to cloxacillm + gentamlcin

TLC. 9,000 Amplctllln + DC, N68 L32 gentanwin

TLC 70,000 DC. N85 L15

Cefotaxmle i gentamlcm

Percutane- ous aSpeE- tion

Percutane- ous aspi- ratmn & later open drainage

NIXi?

Resolution -D20, afe bnle -D5

Resolutmn -D40, afe- brale -D30

Resolwng -D16, afe- brile -D5

Fiesolutlon -020. afe- brile -D9

TLC 38,700 Cloxaclllln + NOW Resolution DC: N87 E2 L9 M2 gentamicln + -D30, afe- AP 250 IU/L metronidazole brile -DlO ALT 25 W/L ECG-myocardltls Ampicillin + Percutane- Died -D2 TLC. 8,000 gentamicin 0”s asp,- DC: N40 E2 L58 ratmn

TLC 20,000 DC: N78 L22

Cefotax1me + NOW Afebnle -D7, gentamwl follow-up

lost

Abbrevwtmns: PEM, proteu-energy malnutrmon, CCF, congestive cardiac fallure; PS, peripheral smear, AP, alkalme phosphatase (normal, 150.200 W/L), ALT, alanine ammotransferase Inormal, 15.50 IUIL); D, day (from date of inmatlon oftreatment). TJVP, increased jugular venous pulse; TLC, total leukocyte count (mm% DC, differential count C%).

*Resolutmn, complete disappearance of abscess cawty, based on last ultrasound examinatmn.

PYOGENIC LIVER ABSCESS 419

past, and another had aplastic anemia and was on long-term steroid therapy. None of the patients had any features suggestive of chronic granulomatous disease or other immunologic disorders. History of passing worms was present in 10 (55.5%) cases, and stool examination results were positive for Ascaris lumbricoides ova in seven (38.9%) and Hookworm ova in four (22.2%) cases.

All patients were symptomatic at presentation, and the duration of symptoms varied from 3 days to 60 days. All the patients had fever. Of the 13 children who could complain, abdomenal pain was present in 10 (76.9%). Tender hepatomegaly was present in 15 cases (83.3%), and four patients (22.2%) had palpable swelling in right hypochondrium. There were two patients who had associ- ated multiple pyogenic subcutaneous abscess. Both these patients were otherwise found to be healthy. Congestive heart failure was present in two patients, one had associated myocarditis and other had severe anemia. Three patients (cases 3, 17, and 1X) had septicemia with septic shock.

Ultrasound scan was performed in all 18 patients with 100% positivity. Lesion was hypoechoic in all and round to oval in 16 patients (88.9%). Margins were mostly irregular (55.5%) and echo poor (72.2%). Twelve (66.0%) patients had internal echoes of varying intensities and patterns. Figures 1 and 2 show ultrasound image of PLA. Number and location of abscesses and other investigative findings are shown in Table 2. An organism was isolated from blood, pus, or both in eleven cases (61.1%). Staphylococcus aureus was the commonest (63.6%) organism isolated. Anaerobic culture was done in four patients and results were negative in all.

All the patients received antibiotics as soon as diagno- sis of PLA was suspected. It was given intravenously for

Fig 1. Ultrasonographic scan of liver (case 9) shows a large, 7.2-cm abscess cavity with echo-poor, irregular margin with internal echoes in right lobe.

Fig 2. Ultrasonographic scan of liver (case 4) shows a large, 4.7-cm abscess cavity with irregular margins in the right lobe. (Al before treatment, (B) after medical treatment.

2 weeks and continued for 2 more weeks orally. Antibi- otic combinations are shown in Table 1. Twelve (66.7%) patients were started on conservative management with antibiotics alone. Metronidazole was added to the initial

Table 2. Investigative Findings

lnvestlgations Positive Percentage

Ultrasound (n = 18)

Single abscess 14 77.8 Right lobe 12 66.7 Left lobe 2 11.1

MultIpIe abscess 4 22.2 Blood culture (n = 17) 7 41.2 Pus culture (n = 12) 5 41.7

Chest x-ray (n = 18) Raised right dome of diaphragm 5 27.8

Pneumonitis 4 22.2

Leukocytosis (n = 18) 11 61.1 Raised liver enzymes (n = 7)

Alanine transaminase 2 28.6

Alkaline phosphatase 5 71.4

large abscess with impending rnpture or when the patient was very sick. Open drainage at presentation was undertaken in two (11.1%) patients (cases 2 and 15), whereas another patient (case 13) required open drainage because of continuous deterioration in spite of antibiotics and percu- taneous aspiration. Indication for the open drainage in one was peritonitis, whereas the other (case 2) underwent open drainage because it was the trend in those days. Two patients (cases 3 and 17) died, giving an overall mortality rate of 11.11%. One infant (case 3) had septicemia with septic shock at admission, with recent history of measles, whereas the other (case 17) had typhoid with liver abscess and myocarditis. Fifteen (83.3%) patients had at least one follow-up ultrasound imaging of the lesion, and in all these patients, lesions were resolving. Ten patients were followed up until complete resolution. The time required for complete resolution ranged from 10 days to 40 days. None of the patients experienced relapse.

DISCUSSION

The incidence of PLA among infants and children has been variously reported, ranging from 3 to 25 per 100,000 pediatric hospital admissions.3.4 Mehta et al had reported on 10 patients with PLA from among 18,024 admitted children under 10 years of age admission during the 1981 to 1985 period.7 The relatively high incidence (78.9 per 100,000 pediatric admissions) of PLA in the present study could be because of the high incidence of pyogenic skin and systemic infections and widespread malnutri- tion. Moreover, this institution is a referral center to many satellite hospitals, and there is routine use of ultrasonog- raphy in the workup of febrile patients with hepato- megaly. High prevalence of worm infestations especially ascariasis could also be a contributory factor. Several studies have incriminated ascariasis as a factor for PLA.9s10J4 Although 55.5% of our patients had a history of passing worms and 38.9% had stool positive for the cyst of A lumbricoides, the general population had similarly high prevalence of worm infestation. Thus, it is difficult to say whether worm infestation predisposes to PLA. In reports from the developed countries, 40% to 45% of PLA occurred among the immunocompromised.3,4

However, the majority of our patients were otherwise healthy, except for moderate to severe protein energy malnutrition in five children. A few other studies, mostly from developing countries, have also documented several cases of PLA among otherwise healthy children.5-7,9Jo One patient recently had measles. There have been earlier reports of PLA after measles.6,*

Fever, abdominal pain, and tender hepatomegaly were present in the majority of cases. This was the observation in several other studies.1-6 Ultrasound scan was found to be sensitive in detecting and localizing abscesses. The role of ultrasound scan in adults with PLA is well documented15-ls but little has been reported in the pediat- ric age group. z.4~16 Several ultrasonographic features are described to be suggestive of PLA. These include round to oval hypoechoic lesions with irregular echo poor margins, internal echoes and a ring of hypoechogenic liver edema surrounding the lesion.15-17 In the present study not all these features were universally present, and they lacked specificity. This has also been noted in other studies.ls-i8 However, diagnosis of PLA could be estab- lished in all cases with ultrasound features in conjunction with other laboratory findings. Ultrasonography was equally useful in the follow-up of these patients. With successful treatment there was a progressive decrease in the size of the abscesses (Fig 2).

Anaerobic organisms are increasingly being reported as a causative agent in PLA in both adults and chil- dren.4J7.19 The anaerobic organisms isolated from chil- dren are Peptosfreptococcus, Bacteroides species, micro- aerophilic streptococci, and others.4J7 Thus, of late anaerobes form the third major group of causative organisms in PLA after Staphylococcus aureus and enteric gram-negative organisms. The low isolation rate of organisms in our study could partly be caused by prior antibiotic therapy before admission and nonavailability of facility for anaerobic culture in most cases in the initial years. S aurez4s accounted for the greatest proportion of the total isolates as also reported in other studies.3.416 Staphylococcus was a common cause, both among the immunocompetent and the immunocompromised. In in- fants, Escherichia coli and Klebsiella were also impor- tant causal agents, as in earlier reports3

A p.enicillinase-resistant penicillin such as cloxacillin with aminoglycoside with or without metronidazole is an optimum initial antibiotic regimen in children beyond infancy. Of the nine patients started on this regimen, eight showed improvement and only one infant (case 3) who had presented with septic shock died on the third day of admission. Among seven patients treated with ampicillin and gentamicin, one patient had worsened necessitating open drainage and antibiotic change, whereas another patient who presented with typhoid myocarditis and septic shock died on the third day after admission. A third

PYOGENIC LIVER ABSCESS 421

generation cephalosporin such as cefotaxime and amino- glycoside would be a good alternative in infants.

Drainage is no longer considered a must in all cases of PLA in adults.9.17 But in pediatrics, most reported series have advocated percutaneous catheter drainage or thera- peutic needle aspiration. 3*4zo-22 However, 10 (55.5%) of our 18 patients did not require drainage and all but one (case 3) showed resolution on follow-up. Few other studies have also shown good outcome with conservative management.9 The mortality rate (11.2%) at this center was lower than those reported in earlier series.3s4,6 Mortality is likely to be higher during infancy and in immunodeficient individuals. The time required for com- plete resolution, which ranged from 10 days to 40 days,

did not show any significant difference among patients without drainage procedure.

Thus, a combination of penicillinase-resistant penicil- lin such as cloxacillin and aminoglycoside is a good initial coverage for PLA in children in developing countries. Combination of third generation cephalosporin and aminoglycoside is a good alternative in infancy. Metronidazole may be added if the response is unsatisfac- tory or culture yields anaerobes. Abscess drainage is warranted in cases with large abscesses, in which there is risk of rupture or when there is lack of response after 48 to 72 hours of appropriate antibiotic therapy. Percutane- ous aspiration is safe and effective. It also avoids the problems of open drainage.

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