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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 270-272

Neonatal liver abscess with impending rupture presenting as abdominal wall swelling: A rare case


1 Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Pathology, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication17-Oct-2017

Correspondence Address:
Aditya Pratap Singh
Near the Mali Hostel, Main Bali Road, Falna, Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_55_17

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  Abstract 


Neonatal liver abscess is a rare entity, and till date, fewer than 100 cases have been reported in the literature. In general, they occur in preterm infants with certain risk factors like umbilical vein catheterization. Treatment consists of aspiration, drainage of the abscess with antibiotics. We are reporting here a case of the liver abscess with impending rupture in a 1-month-old male child.

Keywords: Abscess, impending rupture, liver, neonate


How to cite this article:
Singh AP, Gupta AK, Ansari M, Kumar SM. Neonatal liver abscess with impending rupture presenting as abdominal wall swelling: A rare case. J Clin Neonatol 2017;6:270-2

How to cite this URL:
Singh AP, Gupta AK, Ansari M, Kumar SM. Neonatal liver abscess with impending rupture presenting as abdominal wall swelling: A rare case. J Clin Neonatol [serial online] 2017 [cited 2020 Aug 15];6:270-2. Available from: http://www.jcnonweb.com/text.asp?2017/6/4/270/216911




  Introduction Top


A neonatal liver abscess could be idiopathic, or secondary to umbilical infections due to umbilical vein catheterization or to sepsis which is reported to be the most common predisposing factors. Other predisposing factors include central total parenteral nutrition (TPN) catheters, necrotizing enterocolitis, umbilical and gallbladder or liver surgery, prematurity, and neutrophil defects.[1],[2] Ultrasonography (US) and computerized tomography (CT) with intravenous (IV) contrast are useful for diagnosing this condition. After diagnosis, correction of the predisposing factor (e.g., withdrawal of the umbilical catheter), open or percutaneous drainage of the abscess, and appropriate antibiotic treatment directed at the causative agent is expected to be curative.


  Case Report Top


A 1-month-old male child born by full term normal vaginal delivery was presented to us with abdominal swelling in the right upper quadrant with a history of fever for the past 10 days [Figure 1]. There was no history of umbilical catheterization. Routine blood investigations were within normal limits except total leukocyte counts 22,100/cumm. Ultrasound abdomen revealed a mixed echogenic collection (52 mm × 29 mm) in subcapsular space of the liver and communicating with hepatic parenchyma. CT scan showed a large peripherally enhancing large cystic lesion of size approximate 52 mm × 55 mm × 35 mm seen in the right lobe of liver without intervening hepatic parenchyma anterolaterally suggestive of liver abscess impending to rupture [Figure 2]. Blood culture was sterile. It may be due to use of the antibiotic. We planned for US-guided needle aspiration and around 50cc of thick pus was aspirated. IV antibiotics with the combination of ceftriaxone and metronidazole were started and subsequent pus culture showed growth of Staphylococcus aureus sensitive to vancomycin, amikacin, ampicillin, and linezolid. IV linezolid was added. The patient recovered after drainage and was discharged on oral linezolid for further 2 weeks. A review ultrasound at 2 months showed near complete resolution of the lesion. In our view, liver abscess in the neonatal period is blood born.
Figure 1: Abdominal wall swelling photo

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Figure 2: (a and b) Contrast-enhanced computed tomography images

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  Discussion Top


Liver abscesses may be difficult to diagnose in neonates, partly due to their supposed rarity and lack of suspicion. Signs such as septic appearance, fever, intolerance to feeding, vomiting, abdominal distention, abdominal tenderness, and hepatomegaly are nonspecific, as are laboratory findings such as leukocytosis, neutropenia, thrombocytopenia, increased erythrocyte sedimentation rate, and elevated or normal liver enzymes.[3],[4]

The hepatic abscess can be either multiple or solitary. Multiple liver abscesses as the name suggests are multiple, small in size, not drainable, usually not due to umbilical infection and have a fulminant course. Whereas, solitary liver abscess are larger, well localized, can be drained by surgical methods, usually due to multiple infections such as S. aureus, Streptococcus pyogenes and  Escherichia More Details coli and have a subacute course.

There can be multiple routes of infection to the liver. It can be direct invasion via contagious structure or hepatic artery through systemic circulation or portal vein through an umbilical vein, mesenteric, or splenic vein. Lymph channels along with umbilical vessels can also contribute. Both the rarity of solitary hepatic abscess in the neonate and its indolent course require a high index of suspicion for early diagnosis.

Incorrect placement of umbilical vein catheters and blood culture-proven sepsis are reported to be the most common predisposing factors for liver abscesses, followed by central TPN catheters, necrotizing enterocolitis, surgery, and prematurity with no other associated factors. Neutrophil defects have also been suggested to predispose neonates to liver abscesses.[1],[2] The most common causative pathogens are S. aureus, S. pyogenes, and E. coli. Klebsiella, Pseudomonas, Corynebacterium acnes, anaerobes, and Candida albicans have also been cultured from neonatal liver abscesses. Polymicrobial infection is found in up to 50% of abscesses.[1],[5],[6],[7] In our case, the isolated organism was S. aureus.

Ultrasound abdomen is one of the main tools for the diagnosis. However, sometimes it is difficult to distinguish liver abscess from other hepatic masses such as hepatoblastoma, infantile hemangioendothelioma or hamartoma where CT scan may be helpful.[8] Complications like rupture of liver abscess into the peritoneum, pleural cavity, or portal venous thrombosis are rare in neonates.

Treatment consists of correcting the predisposing factor (e.g., withdrawal of the umbilical catheter), percutaneous drainage with or without ultrasound guidance, or open drainage of the abscess affecting multiple lobes of the liver and/or large abscess as seen in our case. Appropriate antibiotic therapy should be directed to the causative agent.[1],[6] In culture negative lesions, broad spectrum antibiotics covering both Gram-positive, Gram-negative organisms and anaerobes need to be instituted. With prompt diagnosis and appropriate treatment, the outcome seems to be better as compared to a uniformly fatal state, though unfortunately, the mortality rate still can be as high as 50% in spite of appropriate care and treatment.[2] However, the ideal management still remains controversial. One study on neonatal hepatic abscess showed imaging guided aspiration or drainage has a good long-term outcome.[9] Medical management with IV antibiotics is crucial and should be started at the earliest and should be guided according to the sensitivity pattern. Duration of antibiotics should be for a minimum period of 3 weeks.[10]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tan NW, Sriram B, Tan-Kendrick AP, Rajadurai VS. Neonatal hepatic abscess in preterm infants: A rare entity? Ann Acad Med Singapore 2005;34:558-64.  Back to cited text no. 1
    
2.
Shah I, Bhatnagar S. Liver abscess in a newborn leading to portal vein thrombosis. Indian J Pediatr 2009;76:1268-9.  Back to cited text no. 2
    
3.
Lam HS, Li AM, Chu WC, Yeung CK, Fok TF, Ng PC, et al. Mal-positioned umbilical venous catheter causing liver abscess in a preterm infant. Biol Neonate 2005;88:54-6.  Back to cited text no. 3
    
4.
Sethi SK, Dewan P, Faridi MM, Aggarwal A, Upreti L. Liver abscess, portal vein thrombosis and cavernoma formation following umbilical vein catherisation in two neonates. Trop Gastroenterol 2007;28:79-80.  Back to cited text no. 4
    
5.
Sharma S, Mohta A, Sharma P. Hepatic abscess in a preterm neonate. Indian Pediatr 2007;44:226-8.  Back to cited text no. 5
    
6.
Bari S, Sheikh KA, Malik AA, Wani RA, Naqash SH. Percutaneous aspiration versus open drainage of liver abscess in children. Pediatr Surg Int 2007;23:69-74.  Back to cited text no. 6
    
7.
Filippi L, Poggi C, Gozzini E, Meleleo R, Mirabile L, Fiorini P, et al. Neonatal liver abscesses due to candida infection effectively treated with caspofungin. Acta Paediatr 2009;98:906-9.  Back to cited text no. 7
    
8.
Halvorsen RA, Korobkin M, Foster WL, Silverman PM, Thompson WM. The variable CT appearance of hepatic abscesses. Am J Roentgenol 1984;142:941-6.  Back to cited text no. 8
    
9.
Lee SH, Tomlinson C, Temple M, Amaral J, Connolly BL. Imaging-guided percutaneous needle aspiration or catheter drainage of neonatal liver abscesses: 14-year experience. AJR Am J Roentgenol 2008;190:616-22.  Back to cited text no. 9
    
10.
Novak DA, Dolson DJ. Bacterial, parasitic and fungal infections of the liver. In: Suchy FJ, editor. Liver Disease in Children. St. Louis: Mosby; 1994. p. 550-68.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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