Transactions of the Royal Society of Tropical Medicine and Hygiene (2005) 99, 932—936

CASE REPORT

Pyogenic liver abscess in patients withschistosomiasis mansoni

Luciano Z. Goldania,∗, Rodrigo Pires dos Santosa,Alan M. Sugarb,c

a Infectious Diseases Unit, Departmento de Medicina Interna, Hospital de Clınicas de Porto Alegre,Ramiro Barcelos 2350, Porto Alegre, RS, 90035, Brazilb Infectious Disease Clinical Service, Cape Cod Hospital, MA, USAc Section of Infectious Diseases, Evan Memorial Department of Clinical Research,Boston, MA, USA

Received 18 February 2005; received in revised form 20 April 2005; accepted 20 April 2005Available online 12 September 2005

KEYWORDSSchistosomiasis;Liver abscess;Schistosoma mansoni;Pseudomonasaeruginosa;Brazil

Summary Schistosomiasis mansoni has been described as a predisposing factor forpyogenic liver abscess formation. Previous experimental studies have shown thatacute schistosomiasis concurrent with Staphylococcus aureus bacteremia favors thecolonization of the liver by the bacteria, and subsequent pyogenic liver abscessformation. In addition, clinical studies and case reports have demonstrated theassociation of schistosomiasis mansoni with pyogenic liver abscesses. We describea Brazilian patient with chronic schistosomiasis mansoni who developed recurrentpyogenic liver abscesses due to Pseudomonas aeruginosa. The authors review theclinical, diagnostic and treatment aspects of patients with schistosomiasis and pyo-genic liver abscess reported in the medical literature.© 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.All rights reserved.

1. Introduction

Bacterial abscesses of the liver are relativelyuncommon lesions, despite frequency of chole-cystitis, appendicitis, diverticulitis and peritonitis,which are the main sources of bacterial infectionof the liver (Johannsen et al., 2000; Perera et al.,

∗ Corresponding author. Tel.: +55 51 3121 8152;fax: +55 51 3330 3342.

E-mail address: lgoldani@ufrgs.br (L.Z. Goldani).

1980). The incidence of pyogenic abscess is about10 to 20 cases per 100 000 hospital admissions,or 11 cases per million persons per year (Hansenand Schonheyder, 1998; Johannsen et al., 2000). Inthe past, appendicitis with rupture and subsequentspread of infection was the most common route forthe development of a liver abscess. Currently, asso-ciated disease of the biliary tract is the etiologyseen most often.

In Latin America, schistosomiasis has beendescribed as a predisposing factor for pyogenic

0035-9203/$ — see front matter © 2005 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.trstmh.2005.04.018

Schistosomiasis and liver abscess 933

liver abscesses. Previous experimental studies haveshown that acute schistosomiasis concurrent withStaphylococcus aureus bacteremia favors the col-onization of the liver by bacteria, resulting inthe formation of pyogenic liver abscesses (Teixeiraet al., 2001a). In addition, clinical studies andcase reports have demonstrated the associationof schistosomiasis with pyogenic liver abscesses(Lambertucci et al., 1990, 1997, 2001a, 2001b;Lima and Maluf, 1995; Teixeira et al., 1996, 1997,2001b).

The authors describe a Brazilian patient withchronic schistosomiasis mansoni who developedrecurrent pyogenic liver abscesses caused byPseudomonas aeruginosa. The authors reviewthe clinical, diagnostic and treatment aspectsof patients with schistosomiasis mansoni andliver pyogenic abscess reported in the medicalliterature.

2. Case report

A 43-year-old white Brazilian man was seen for eval-uation of upper right quadrant pain and fevers.Ttaahigdaifm

optaqblm

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Figure 1 CT of the abdomen, showing an abscess in theperiphery of the right lobe of the liver in a patient withchronic schistosomiasis.

partial clinical response with long-term antibi-otics, the patient underwent a laparotomy forremoval of the liver abscess. Cultures again grewP. aeruginosa. The patient was discharged fromthe hospital, and made a gradual and completerecovery.

3. Discussion

Parasitism with Schistosoma mansoni affects>100 million people in 75 countries (WHO, 1993). Inthe USA, infection with human schistosomiasis hasbeen estimated to exceed 400 000 persons, mostlyimmigrants from endemic areas, such as Brazil,Puerto Rico, The Middle East and The Philippines(Warren, 1974). In schistosomiasis mansoni, manyeggs remain in the venous portal circulation andare carried into the liver. The disease associatedwith schistosomiasis is largely due to the host’simmune response to the larvae and eggs. Theeggs induce granuloma formation, which resultsin a pre-sinusoidal block to portal flow and inthe development of portal hypertension andportosystemic collateral circulation (Hiatt et al.,1

pshta

he patient has a relevant past medical his-ory of chronic schistosomiasis mansoni, and had

laparotomy with portal-systemic shunt 5 yearsgo. Approximately 2 years earlier, the patientad developed a pyogenic liver abscess follow-ng a laparoscopic cholecystectomy, and culturesrew only P. aeruginosa. This was percutaneouslyrained and successfully treated with intravenousntibiotics for 2 months. The patient had been liv-ng in the USA for approximately 3 years, and exceptor the above events, was doing well, without anyedical problems.Physical examination revealed a blood pressure

f 120/70 mmHg, a temperature of 38.5 ◦C, a res-iration of 19 and a heart rate of 102 bpm. Besideshe presence of hepatosplenomegaly, the patient’sbdomen was painful to palpation in the right upperuadrant. Laboratory testing revealed a whitelood cell count of 16 000 cells/mm3, a hemoglobinevel of 11.7 g/dl, platelets of 30 000/mm3 and nor-al liver enzymes.Computerized tomography (CT) scan and ultra-

onography of the abdomen showed a 3-cm liverbscess (Figure 1). The patient underwent twoercutaneous drainages of the liver abscess. Purerowth of P. aeruginosa was isolated from theurulent material. Considering the susceptibil-ty of P. aeruginosa, the patient was treatedith intravenous ciproflaxacin for 60 d, followedy intravenous ceftazidime for 90 d, with par-ial resolution of the abscess. Considering the

979).Several pathogenic mechanisms have been pro-

osed to explain the association between schisto-omiasis mansoni and pyogenic liver abscesses. Itas been demonstrated that bacteria avidly bindo fibronectin, laminin and type IV collagen, whichre abundant during the more active stages of the

934L.Z.

Goldaniet

al.

Table 1 Characteristics of patients with schistosomiasis and pyogenic abscesses

Age (years)/sex Clinical manifestations Schistosomiasis Liver abscess Pathogen Treatment Outcome Reference

14/male Fever, nausea,abdominal pain,furuncle

Acute Multiple S. aureus Oxacillin, amikacin,percutaneous drainage

Alive Lambertucci et al., 1997

8/male Fever, nausea,vomiting, diarrhea,abdominal pain

Acute Multiple S. aureus Oxacillin, clindamycin,laparotomy, drainage

Alive Teixeira et al., 1996

10/male Fever, diarrhea,abdominal pain,furuncle

Acute Multiple S. aureus Oxacillin, amikacin,laparotomy, drainage

Alive Teixeira et al., 1996

10/male Fever, vomiting,abdominal pain,furuncle

Acute Multiple S. aureus Oxacillin, amikacin,laparotomy, drainage

Alive Teixeira et al., 1996

10/male Fever, weakness,weight loss, diarrhea,abdominal pain,furuncle

Acute Multiple S. aureus Oxacillin, clindamycin,laparotomy, drainage

Alive Lambertucci et al., 1990

10/male Fever, vomiting,abdominal pain,folliculitis

Acute Multiple S. aureus Oxacillin, amikacin,laparotomy, drainage

Alive Lambertucci et al., 1990

8/male Fever, vomiting,abdominal pain

Acute Single S. aureus Clindamycin, oxacillin,gentamicin,laparotomy, drainage

Alive Lambertucci et al., 2001a

5/male Fever, malaise,abdominal pain

Acute Single S. aureus Oxacillin, amikacin,laparotomy, drainage

Alive Teixeira et al., 2001b

47/male Fever, jaundice, lumbarpain, neck abscess,dental infection

Chronic Single S. aureus Oxacillin, percutaneousdrainage

Alive Lambertucci et al., 2001b

37/female Fever, fatigue,vomiting, abdominalpain, recenthysterectomy

Chronic Single ? Oxacillin, gentamicin,metronidazole,percutaneous drainage,laparotomy

Alive Lima and Maluf, 1995

Schistosomiasis and liver abscess 935

granuloma. In addition, the formation and degra-dation of extracellular matrix and laminin of thechronic granuloma may also be implicated in thepathogenesis of the abscesses (Andrade, 1991;Andrade and Grimaud, 1988; Vercellotti et al.,1985). Besides a local adhesion mechanism, theimmune response in schistosomiasis infection mayplay a role in the pathogenesis of this associa-tion. The inhibition of Th1 immune response notedafter the deposition of eggs can affect the normalresponse to the presence of bacteria (Grzych et al.,1991; Pearce et al., 1991).

We were able to find 10 cases of schistoso-miasis mansoni and pyogenic abscesses reportedin the medical literature (Table 1). By contrastto our patient, eight out of 10 of the patientswere children ranging from 5 to 14 years oldwith acute schistosomiasis, who developed mul-tiple pyogenic abscesses. Similar to our patient,the two adult patients with chronic schistoso-miasis developed single liver pyogenic abscesses.Clinical manifestations of the reported patientsincluded right upper quadrant abdominal pain andfever consistent with pyogenic liver abscess. Thebacteria most commonly isolated from the liveracoadoaoctagpasatiuhtwa

odplsis

Conflicts of interest statementThe authors have no conflicts of interest concerningthe work reported in this paper.

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