Molecular mechanism of Xuebijing in treating pyogenic liver abscess complicated with sepsis

BACKGROUND:Xuebijing(XBJ)can alleviate the inflammatory response,improve organ function,and shorten the intensive care unit(ICU)stay in patients with pyogenic liver abscess(PLA)complicated with sepsis,but the molecular mechanisms have not been elucidated.This study aimed to explore the molecular mechanism of XBJ in treating PLA complicated with sepsis using a network pharmacology approach.METHODS:The active ingredients and targets of XBJ were retrieved from the ETCM database.Potential targets related to PLA and sepsis were retrieved from the GeneCards,PharmGKB,DisGeNet,Online Mendelian Inheritance in Man(OMIM),Therapeutic Targets Database(TTD),and DrugBank databases.The targets of PLA complicated with sepsis were mapped to the targets of XBJ to identify potential treatment targets.Protein-protein interaction networks were analyzed using the STRING database.Potential treatment targets were imported into the Metascape platform for Gene Ontology(GO)functional enrichment and Kyoto Encyclopedia of Genes and Genomes(KEGG)pathway enrichment analyses.Molecular docking was performed to validate the interactions between active ingredients and core targets.RESULTS:XBJ was found to have 54 potential treatment targets for PLA complicated with sepsis.Interleukin-1β(IL-1β),interleukin-6(IL-6),and tumor necrosis factor(TNF)were identifi ed as core targets.KEGG enrichment analysis revealed important pathways,including the interleukin-17(IL-17)signaling pathway,the TNF signaling pathway,the nuclear factor-kappa B(NF-κB)signaling pathway,and the Toll-like receptor(TLR)signaling pathway.Molecular docking experiments indicated stable binding between XBJ active ingredients and core targets.CONCLUSION:XBJ may exert therapeutic eff ects on PLA complicated with sepsis by modulating signaling pathways,such as the IL-17,TNF,NF-κB,and TLR pathways,and targeting IL-1β,IL-6,and TNF.

Primary hepatic lymphoma presenting as pyogenic liver abscess:A case report

BACKGROUND Primary hepatic lymphoma(PHL)is a lymphoproliferative disorder confined to the liver without peripheral lymph node involvement and bone marrow invasion.PHL is extremely rare in clinical practice.The etiology and pathogenesis of PHL are largely unknown.There are no common standard protocols or guidelines for the treatment of PHL.CASE SUMMARY We report the case of a 66-year-old man who presented with fever and abdominal pain for three weeks.Computed tomography and magnetic resonance imaging scans showed a pyogenic liver abscess.The patient underwent a right posterior hepatectomy.The surgical pathology revealed aggressive B-cell lymphoma,with a primary consideration of diffuse large B-cell lymphoma of non-germinal center origin.CONCLUSION This article reviews the characteristics,mechanism and treatment of PHL and provides insight into the diagnosis of PHL.

Profile of Amoebic vs. Pyogenic Liver Abscess and Comparison of Demographical, Clinical, Radiological, and Laboratory Profiles of These Patients from Three Secondary Care Centers in Senegal

Background: Liver abscess (LA) is a suppurated collection in the hepatic parenchyma. In Africa, liver abscesses are most often of amoebic origin, but more recently, the rate of pyogenic liver abscesses (PLA) has increased. Objective: to assess the epidemiological characteristics, clinical features, biological radiological findings, and outcomes of patients with PLA and with amebic liver abscess (ALA) in order to determine the potential factors that may help improve diagnosis and treatment for LA in the context of secondary care centers with limited medical supports. Methods: Retrospective review of LA diagnosed and treated at three secondary care centers in Thiès over 11 years. Results: 61 patients, were included, 52.45% had ALA and 47.54% had PLA. Males were predominant (79.31% in PLA vs 65.63% in ALA, p = 0.2). The median age was 38 years for the PLA group vs 39 years for the ALA group (p = 0.4). In both groups, the most common symptom was right upper abdominal pain (81.97%), hepatomegaly (81.97%). The PLA group had a higher prevalence of fever (79.31% vs 46.88%, p = 0,009), chills (51.72% vs 18.75%, p = 0.007), right basi-thoracic pain (55.17% vs 28.13%, p = 0.032), and jaundice (55.17% vs 28%, p = 0.032). There was no difference in radiological features between PLA and ALA. Patients with PLA had a higher level of White blood cell (20.600 vs 15.400, p = 0.014). The most common bacteria identified in PLA were Escherichia coli (58.8%). All patients had received antibiotic therapy, which was combined with aspiration puncture (37.3%), transcutaneous drainage (43.3%), and surgery (9.0%). Seven patients had received antibiotic therapy alone and all had amoebic abscesses. Elsewhere, the occurrence of complications was higher in PLA cases (75.86% vs 37.5%, p = 0.003). The overall hospital mortality rate was 13.11%, higher in cases of PLA (24.14% vs 3.13%, p = 0.022). Conclusion: Clinical and biological features were more severe in PLA. But radiological features cannot be used to distinguish between PLA and ALA.

Pyogenic liver abscess:An audit of 10 years’experience

AIM:To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.METHODS:A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre,were reviewed.Amoebic and hydatid abscesses were excluded.Demographic,clinical,radiological,and microbiological characteristics,as well as surgical/radiological interventions,were recorded.RESULTS:Sixty-three patients(42 males,21 females) aged 65(±14) years[mean±(SD) ]had prodromal symptoms for a median(interquartile range;IQR) of 7(5-14) d.Only 59%of patients were febrile at presentation;however,the serum C-reactive protein was elevated in all 47 in whom it was measured.Liver function tests were non-specifically abnormal.67%of patients had a solitary abscess,while 32%had>3 abscesses with a median(IQR) diameter of 6.3(4-9) cm.Causative organisms were:Streptococcus milleri 25%,Klebsiella pneumoniae 21%,and Escherichia coli 16%.A presumptive cryptogenic cause was most common (34%).Four patients died in this series:one from sepsis,two from advanced cancer,and one from acute myocardial infarction.The initial procedure was radiological aspiration±drainage in 54 and surgery in two patients.17%underwent surgical management during their hospitalization.Serum hypoalbuminaemia[mean (95%CI) :32(29-35) g/L vs 28(25-31) g/L,P=0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.CONCLUSION:PLA is a diagnostic challenge,because the presentation of this condition is non-specific.Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs;However,a small proportion of patients still require surgical drainage.

Pyogenic liver abscesses associated with nonmetastatic colorectal cancers: An increasing problem in Eastern Asia

AIM: To elaborate the clinicopathologic features of colorectal cancer-related pyogenic liver abscess (PLA). METHODS: Reported cases of colorectal cancer-related PLAs were collected from the literature published up to October 2011 and evaluated for their clinicopathologic features. Data of collected cases included demographics, clinical presentation, microbial findings and treatment. Categorical variables were compared by 2 analysis and continuous variables were evaluated using Student's t test. RESULTS: A total 96 cases of colorectal cancer-related PLA were collected from the previous literature. Most patients (60%) were male and 40% cases occurred in the age group of 61-70 years. Apart from some special types of PLA, there were significant differences in the microbiological spectrum between Eastern Asia and non-Eastern Asian countries, which implied different risk factors and courses of the disease. Gram negative bacteria especially Klebsiella pneumoniae (K. pneu- moniae ) PLA was predominant in Eastern Asia (80.0%) in contrast to non-Eastern Asian countries (P < 0.01). Meanwhile, most of the Eastern Asian patients exhibited smaller size of liver abscess and atypical presentation. Sigmoid colon and rectum (72.73%) were the main sites of tumor in Eastern Asian patients, whereas tumor sites were uneven among most of the non-Easter Asian PLA patients. CONCLUSION:K. pneumoniae PLA was strongly associated with colorectal cancer, especially those occurring in sigmoid colon and rectum, in elderly Eastern Asian male patients.

A middle-aged lady with a pyogenic liver abscess caused by Clostridium perfringens

The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens ) is a rare, but rapidly fatal infection. It is usually associated with malignancy and immunosuppression. We report the case of 50-year-old lady with the secondary liver metastases from rectal cancer presented with fever and epigastric pain. The identification of Grampositive bacilli septicaemia, the presence of gas-forming liver abscess and massive intravascular hemolysis should lead to the suspicion of C. perfringens infection. Here we review twenty cases published since 1990 and their clinical features are discussed. The importance of "an aggressive treatment policy" with multidisciplinary team approach is emphasized.

Recent upper gastrointestinal panendoscopy increases the risk of pyogenic liver abscess

AIM To investigate the association between a recent gastrointestinal(GI) endoscopy and the subsequent risk of pyogenic liver abscess(PLA).METHODS We designed a nested case control study. Using the Taiwan National Health Insurance Research Database, 2135 patients with a first diagnosis of PLA were identified from 1998 to 2011. Another 10675 patients without PLA matched by age and sex were selected as reference controls. We identified and compared the possible risk factors for PLA and GI endoscopies performed before the index date(when PLA was diagnosed) between the two cohorts. Multivariate analysis was conducted to examine the risk of PLA within the 90 d after the GI endoscopies.RESULTS Patients with a history of diabetes [adjusted odds ratio(a OR) = 4.92, 95%CI: 1.78-13.61], end-stage renal disease(a OR = 3.98, 95%CI: 1.45-10.91), biliary tract infection(a OR = 2.68, 95%CI: 2.11-3.40), liver cirrhosis(a OR = 2.19, 95%CI: 1.39-3.46), GI malignancies(a OR = 5.68, 95%CI: 4.23-7.64), appendicitis(a OR = 3.16, 95%CI: 2.27-4.41), diverticulitis(a OR = 1.64, 95%CI: 1.01-2.64), and recent endoscopic retrograde cholangiopancreatography(a OR = 27.04, 95%CI: 11.65-62.72) were significantly associated with an increased risk of PLA. After adjusting for the above risk factors and the frequency of outpatient department visits and abdominal ultrasounds during 90 d before the index date, an upper GI panendoscopy(a OR = 2.75, 95%CI: 2.05-3.69) but not a lower GI endoscopy(a OR = 1.07, 95%CI: 0.62-1.86) was significantly associated with PLA.CONCLUSION An upper GI panendoscopy performed before 90 d may increase the risk of PLA.

Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

AIM:To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy. METHODS:The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and out-come of surgery. RESULTS:The patients were predominantly women (10/13) with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multilocula-tion. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy:two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with perito-nitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism. CONCLUSION:Surgical treatment of pyogenic liver ab-scess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.

Patients with culture negative pyogenic liver abscess have the same outcomes compared to those withKlebsiella pneumoniae pyogenic liver abscess

BACKGROUND: Etiologic organism is not frequently isolated despite multiple blood and lfuid cultures during management of pyogenic liver abscess (PLA). Such culture negative pyogen-ic liver abscess (CNPLA) is routinely managed by antibiotics targeted toKlebsiella pneumoniae. In this study, we evaluated the outcomes of such clinical practice. METHODS: All the patients with CNPLA andKlebsiella pneu-moniaePLA (KPPLA) admitted from January 2003 to Decem-ber 2011 were included in the study. A retrospective review of medical records was performed and demographic, clinical and outcome data were collected. RESULTS: A total of 528 patients were treated as CNPLA or KPPLA over the study period. CNPLA presented more com-monly with abdominal pain (P=0.024). KPPLA was more com-mon in older age (P=0.029) and was associated with thrombo-cytopenia (P=0.001), elevated creatinine (P=0.002), bilirubin (P=0.001), alanine aminotransferase (P=0.006) and C-reactive protein level (P=0.036). CNPLA patients tend to have anemia (P=0.015) and smaller abscess (P=0.008). There was no differ-ence in hospital stay (15.7 vs 16.8 days) or mortality (14.0% vs 11.0%). No patients required surgical drainage after initiation of medical therapy. CONCLUSION: Despite demographic and clinical differences between CNPLA and KPPLA, overall outcomes are not different.

Pyogenic liver abscess caused by Fusobacterium in a 21-year-old immunocompetent male

A 21-year-old male with no significant past medical history, presented with right upper quadrant(RUQ) abdominal pain along with fevers and chills. Lab work revealed leukocytosis, anemia, and slightly elevated alkaline phosphatase. Viral serology for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative and he was immunocompetent.Computed tomography imaging revealed hepatic abscesses, the largest measuring 9.5 cm. Empiric antibiotics were started and percutaneous drains were placed in the abscesses. Anaerobic cultures from the abscesses grew Fusobacterium nucleatum. This is a gram negative anaerobic bacteria; a normal flora of the oral cavity. Fusobacterium is most commonly seen in Lemiere's disease, which is translocation of oral bacteria to the internal jugular vein causing a thrombophlebitis and subsequent spread of abscesses. Our patient did not have Lemiere's, and is the first case described of fusobacterium pyogenic liver abscess in a young immunocompetent male with good oral hygiene. This case was complicated by sepsis, empyema, and subsequent abscesses located outside the liver. These abscesses' have the propensity to flare abruptly and can be fatal. This case not only illustrates fusobacterium as a rare entity for pyogenic liver abscess, but also the need for urgent diagnosis and treatment. It is incumbent on physicians to diagnose and drain any suspicious hepatic lesions. While uncommon, such infections may develop without any overt source and can progress rapidly. Prompt drainage with antibiotic therapy remains the cornerstone of therapy.

Single-level Lumbar Pyogenic Spondylodiscitis Treated with Minimally Invasive Anterior Debridement and Fusion Combined with Posterior Fixation via Wiltse Approach

Summary： The effect and safety of anterior debridement and fusion with a minimally invasive ap- proach combined with posterior fixation via the Wiltse approach were assessed in the single-level lum- bar pyogenic spondylodiscitis. Seventeen patients from 2007 to 2009 underwent anterior debridement and fusion with a minimally invasive approach combined with posterior fixation via the Wiltse approach. Postoperative follow-up time was 24-41 months. Data included the patients＇ general information, mi- crobiology, operative time, intraoperative blood loss, postoperative complications, intervertebral fusion rate, and preoperative and final follow-up scores for American Spinal Injury Association （ASIA） im- pairment, visual analogue scale （VAS）, and Oswestry Disability Index （ODI）. Ten patients had under- gone a prior spinal invasive procedure, and 7 had hematogenous infection. The infected segments in- cluded L1-2, L2-3, L3,~, and L4-5 in 1, 2, 5, and 9 cases, respectively. Thirteen bacterial cultures were posi- tive for Staphylococcus aureus （5 cases）, Staphylococcus epidermidis （4）, Streptococcus （3）, and Es- cherichia coli （1）. The operative time was 213.8＋45.6 min, and the intraoperative blood loss was 180.6-4-88.1 mL. Postoperative complications consisted of urinary retention （2 cases）, constipation （3）, and deep vein thrombosis （2）. On the final follow-up, VAS scores and ODIs were significantly lower than those of preoperation, while the ASIA grades improved. All the cases achieved good intervertebral bony fusion. Anterior debridement and fusion with a minimally invasive approach combined with poste- rior fixation via the Wiltse approach can successfully treat single-level lumbar pyogenic spondy- lodiscitis, with less trauma and reliable immobilization. It is a viable option for clinical application.

Increased incidence of and microbiologic changes in pyogenic liver abscesses in the Mexican population

BACKGROUND Pyogenic liver abscess(PLA)is a rare disease with an estimated incidence that varies widely across the globe,being as high as 115.4/100000 habitants in Taiwan and as low as 1.1-1.2/100000 habitants in Europe and Canada.Even though there are multiple microorganisms capable of producing an abscess in the liver,including Entamoeba histolytica,fungi,and viruses,most abscesses are derived from bacterial infections.The epidemiology of PLA in Mexico is currently unknown.AIM To describe the clinical,demographic and microbiologic characteristics of PLA in Mexico.METHODS This is a retrospective study carried out in two centers,and included patients seen between 2006 and 2018 with the diagnosis of pyogenic abscess.We collected demographic,clinical,and microbiological information,treatment,complications,and outcomes.A logistic regression analysis was used to determine the association between different variables and mortality rates.RESULTS A total of 345 patients were included in this study.233(67.5%)had confirmed PLA,133(30%)patients had no positive culture and negative serology and 9(2.5%)had mixed abscesses.The mean age was 50 years(ranging from 16-97 years)and 63%were female.65%of the patients had positive cultures for Extended Spectrum Beta-Lactamases(ESBL)-Escherichia coli and Klebsiella pneumoniae.Cefotaxime was administered in 60%of cases.The most common sources of infection were ascending cholangitis and cholecystitis in 34(10%)and 31(9%),respectively.The median length of hospital stay was 14 d.165 patients underwent percutaneous catheter drainage.The inpatient mortality rate was 63%.Immunocompromised state[OR 3.9,95%CI:1.42-10.46],ESBL-Escherichia coli[OR 6.7,95%CI:2.7-16.2]and Klebsiella pneumoniae[OR 4-8,95%CI:1.6-14.4]predicted inpatient mortality by multivariate analysis.CONCLUSION The prevalence of PLA is increasing in Mexico and has a very high mortality rate.ESBL-Escherichia coli and Klebsiella pneumoniae are the most common microorganisms causing PLA and are independent predictors of inpatient mortality.

Pyogenic liver abscess associated with large colonic tubulovillous adenoma

Pyogenic liver abscesses usually occur in association with a variety of diseases. Rarely, liver abscess has been reported as the presenting manifestation of colonic tubulovillous adenoma. We report two cases of pyogenic liver abscess without hepatobiliary disease or other obvious etiologies except that one had a history of diabetes mellitus （DM）. The pathogen in the patient with DM was Klebsiella pneumonia （KP）. In both of the patients, Ueus developed about two to three weeks after the diagnosis of liver abscess. Colonoscopy revealed large polypoid tumors with pathological findings of tubulovillous adenoma in both cases. Two lessons were learned from these two cases： （1） an underlying cause should be aggressively investigated in patients with cryptogenic liver abscess; （2） DM could be one of the etiologies but not necessarily the only cause of KP liver abscess.

Is hepatic neoplasm-related pyogenic liver abscess a distinct clinical entity?

AIM: To compare the clinical characteristics of pyogenic liver abscess (PLA) in patients with and without hepatic neoplasm (HN). METHODS: We performed a retrospective analysis involving patients with PLA. The demographic, clinical features, laboratory and imaging findings, management and outcome of patients with and without HN were studied. RESULTS: From January 2000 to December 2009 inclusive, 318 patients (35 with HN) had PLA, and mean age and comorbidity were comparable between the two groups. More patients with HN experienced right upper quadrant pain (68.6% vs 52.7%, P < 0.04), developed jaundice (14.3% vs 5.7%, P < 0.03) and hepatomegaly (17.1% vs 3.9%, P < 0.01), and had higher serum total bilirubin level (43.3 μmol/L vs 30.0 μmol/L, P = 0.05). Most patients in both groups had PLAs in the right hepatic lobe, and biliary tract disorder was the most common underlying cause (71.4% and 61.8%). However, more PLAs in the HN group were associated with thicker abscess wall (37.1% vs 19.4%, P < 0.01), septal lobulation (77.1% vs 58%, P < 0.02), gaseous cavitation (17% vs 7.8%, P = 0.03), portal thrombophlebitis (11.4% vs 1.8%, P < 0.01) and aerobilia (25.9% vs 5.5%, P < 0.01). Mixed bacterial growth (40% vs 15.2%, P < 0.01) and Gram-negative bacilli (22.8% vs 60.4%, P < 0.01) were dominant isolates in PLAs with and without HN, respectively. Although incidence of the complications was comparable between the two groups, patients with HN had a higher mortality rate than those without (71.4% vs 8.8%, P < 0.01). Multivariate logistic regression analysis revealed underlying active malignancy [odds ratio (OR): 40.45, 95% CI: 14.76-111.65], hypoalbuminemia (OR: 1.22, 95% CI: 1.14-1.38), disseminated intravascular coagulation (OR: 3.32, 95% CI: 1.19-9.69) and acute coronary syndrome (OR: 4.48, 95% CI: 1.08-17.8) were independent risk factors associated with mortality. However, several HN cases, presented concurrently with PLAs, were found to have curative resectable tumors and had good prognosis after surgery. CONCLUSION: PLA associated with HN tends to form a distinct clinical syndrome with a different extent of clinical manifestations, radiological and microbiological features and complications.

Successful treatment of pyogenic ventriculitis caused by extensively drug-resistant Acinetobacter baumannii with multi-route tigecycline: A case report

BACKGROUND Pyogenic ventriculitis caused by extensively drug-resistant Acinetobacter baumannii(A.baumannii)is one of the most severe complications associated with craniotomy.However,limited therapeutic options exist for the treatment of A.baumannii ventriculitis due to the poor penetration rate of most antibiotics through the blood-brain barrier.CASE SUMMARY A 68-year-old male patient with severe traumatic brain injury developed pyogenic ventriculitis on postoperative day 24 caused by extensively drug-resistant A.baumannii susceptible to tigecycline only.Successful treatment was accomplished through multi-route administration of tigecycline,including intravenous combined with continuous ventricular irrigation plus intraventricular administration.The pus was cleared on the 3rd day post-irrigation,and cerebrospinal fluid cultures were negative after 12 d.CONCLUSION Our findings suggest that multi-route administration of tigecycline can be a therapeutic option against pyogenic ventriculitis caused by extensively drugresistant A.baumannii.

Differentiation of pyogenic hepatic abscesses from malignant mimickers using multislice-based texture acquired from contrast-enhanced computed tomography

BACKGROUND： Pyogenic hepatic abscess may mimic primary or secondary carcinoma of the liver on contrast-enhanced computed tomography（CECT）. The present study was to explore the usefulness of the analysis of multislice-based texture acquired from CECT in the differentiation between pyogenic hepatic abscesses and malignant mimickers.METHODS： This retrospective study included 25 abscesses in 20 patients and 33 tumors in 26 subjects who underwent CECT. To make comparison, we also enrolled 19 patients with hepatic single simple cyst. The images from CECT were analyzed using a Laplacian of Gaussian band-pass filter（5 filter levels with sigma weighting ranging from 1.0 to 2.5）. We also quantified the uniformity, entropy, kurtosis and skewness of the multislice-based texture at different sigma weightings. Statistical significance for these parameters was tested with oneway ANOVA followed by Tukey honestly significant difference（HSD） test. Diagnostic performance was evaluated using the receiver operating characteristic（ROC） curve analysis.RESULTS： There were significant differences in entropy and uniformity at all sigma weightings（P〈0.001） among hepatic abscesses, malignant mimickers and simple cysts. The significant difference in kurtosis and skewness was shown at sigma 1.8 and 2.0 weightings（P=0.002-0.006）. Tukey HSD testshowed that the abscesses had a significantly higher entropy and lower uniformity compared with malignant mimickers（P=0.000-0.004）. Entropy（at a sigma 2.0 weighting） had the largest area under the ROC curve（0.888） in differentiating abscesses from malignant mimickers, with a sensitivity of 81.8% and a specificity of 88.0% when the cutoff value was set to 3.64.CONCLUSION： Multislice-based texture analysis may be useful for differentiating pyogenic hepatic abscesses from malignant mimickers.

Pyogenic liver abscess secondary to gastric perforation of an ingested toothpick:A case report

BACKGROUND Liver abscess due to foreign body-induced gastrointestinal tract perforation is a rare event that could be misdiagnosed due to low suspicion.Less than 100 cases have been reported to date.CASE SUMMARY We report a case of a 53-year old female patient with pyogenic liver abscess secondary to ingestion of a toothpick with penetration through the lesser curvature of the stomach.The patient presented with persistent epigastric pain.Abdominal computed tomography demonstrated the presence of a linear radiopaque object associated with abscess formation in the left liver lobe.Inflammatory changes in the lesser curvature of the stomach indicated gastric wall penetration by the object.As the abscess was refractory to antibiotic treatment,laparoscopic liver resection was performed to remove the foreign body and adjacent liver parenchyma.Following surgery,symptoms fully resolved without any sequelae.CONCLUSION This rare case demonstrates the importance of considering foreign body penetration as a cause of pyogenic liver abscess,particularly in abscesses of unknown origin that are resistant to antibiotic therapy.Clinical suspicion,early diagnosis,and prompt removal of the foreign body could lead to improved outcomes in these patients.

Evaluation of Percutaneous Pedicle Screw Fixation in Patients with Pyogenic Spondylitis of the Thoracolumbar Spine

Background: Basic principle for the treatment of pyogenic spondylitis (PS) is conservative care, but surgical intervention is often required when conservative treatment may fail. We have experienced many conservative cases of various complications due to long-term bed rest and poor pain control. Recently we have adopted percutaneous pedicle screw (PPS) fixation for the treatment of PS as a minimally invasive spine stabilization (MISt) fusion to reduce such morbidity of the conservative care. Objective: To evaluate the impact of PPS fixation in patients with PS. Study Design: A retrospective analysis of the medical records. Subjects, Methods: We reviewed 54 consecutive patients who underwent treatment in our hospital for PS during 2005-2018 and observed for more than 12 months. Of those we excluded cases showing effectiveness to initial treatment (it was defined fever relief or C-reactive protein (CRP) inversion in 3 weeks of antibiotics) so that this study is a retrospective study in cases showing initial treatment resistance. Finally, this study included 29 cases. Medical records of these 29 cases were reviewed for baseline, organism isolated and its detection rate, the clinical outcome in 12 months (Discharge, Transfer, Death), the period from the first visit to our hospital to fever relief, CRP inversion, ambulation, and Discharge or Transfer. Results: These cases were divided into two groups, the conservative group (C-group): 17 cases, and the PPS group (P-group): 12 cases. There is no statistically significant difference in fever relief (p = 0.051) and CRP inversion (p = 0.208). The period to ambulation and discharge or transfer was significantly shorter in group P (p = 0.020, p = 0.031). 1-Year survival rate was 92% in the P-group, and 71% in the C-group. There is no statistically significant difference (p = 0.354) between the two groups. The rate of Discharge to home and care facility is 58% in P-group, and 47% in C-group. And the rate of Transfer is 34% in P-group, and 35% in C-group. Conclusion: PPS fixation was effective to achieve shortening the period to ambulation and discharge or transfer. But it was not effective in infection control. This suggests that PPS fixation should be aggressively administered to patients who can expect pain relief and early ambulation by PPS fixation in the patient of PS showing resistance to initial treatment.

Are our endoscopy patients at risk for pyogenic liver abscess?

This is an editorial comment on a recent publication reporting an increased rate of pyogenic liver abscesses(PLAs) after upper gastrointestinal panendoscopy. Its aim is to critically highlight the findings, limitations and potential clinical implications of this study. Issues of the mucosal barrier, the microbial flora, administration of antibiotics and underlying diseases are discussed. The probability of PLAs after endoscopies is not exactly known and the length of the "incubation period" remains unclear, but a possible causality should already suffice to make us think how to avoid them. Especially in patients with risk factors such as diabetes mellitus, end-stage renal disease, liver cirrhosis, biliary tract infection, and malignancies, the potential risk for PLAs should be considered. Unnecessary insufflation during endoscopy(causing mucosal stretching and microscopic tears) as well as mucosal damage(by direct abrasion with the scope) should be avoided in order to limit the invasiveness of the procedure as much as possible. And, in everyday routine, it should be kept in mind that in patients after endoscopy, especially in those with a breach of the mucosal barrier and significant comorbidities, PLAs can potentially develop and require timely administration of antibiotics as well as further diagnostic and therapeutic steps.

Endoscopic nasal surgery for mucocele and pyogenic mucocele of turbinate: Three case reports

BACKGROUND Cases of turbinate mucocele or pyogenic mucocele are extremely rare.During nasal endoscopy,turbinate hypertrophy can be detected in patients with turbinate or pyogenic mucocele.However,in many instances,differentiating between turbinate hypertrophy and turbinate mucocele is difficult.Radiological examinations,such as computed tomography(CT)or magnetic resonance imaging(MRI),are essential for the accurate diagnosis of turbinate mucocele.Herein,we report three cases of mucocele or pyogenic mucocele of turbinate,including their clinical presentation,imaging findings,and treatments,to help rhinologists understand this condition better.CASE SUMMARY Three cases of turbinate and pyogenic mucocele were encountered in our hospital.In all patients,nasal obstruction and headache were the most common symptoms,and physical examination revealed hypertrophic turbinates.On CT scan,mucocele appeared as non-enhancing,homogeneous,hypodense,well-defined,rounded,and expansile lesions.Meanwhile,MRI clearly illustrated the cystic nature of the lesion on T2 sequences.Two patients with inferior turbinate mucocele underwent mucocele lining removal,while the patient with pyogenic mucocele underwent endoscopic middle turbinate marsupialization.The patients were followed up on the first,third,sixth month,and 1 year after discharge,and no complaints of headache and nasal congestion were reported during this period.CONCLUSION In conclusion,both CT and MRI are helpful in the diagnosis of turbinate or pyogenic mucocele.Additionally,endoscopic nasal surgery is considered to be the most effective treatment method.