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Klebsiella pneumoniae Renal Abscess Syndrome: A Rare Case with Metastatic Involvement of Lungs, Eye, and Brain  [PDF]
Divyanshu Dubey,Fayez S. Raza,Anshudha Sawhney,Ambarish Pandey
Case Reports in Infectious Diseases , 2013, DOI: 10.1155/2013/685346
Abstract: We describe a rare case of Klebsiella pneumoniae renal abscess with metastatic spread leading to endopthalmitis, pulmonary cavitary lesions, and cerebral emboli in a 41-year-old Hispanic female with diabetes mellitus who presented with a four-to-five-day history of fevers, headache, eye pain, and vomiting. She was treated with IV antibiotics and made a gradual but full recovery. 1. Introduction Klebsiella pneumoniae, a member of the Enterobacteriaceae family, is a virulent Gram negative organism that causes nosocomial infections. It has a higher tendency to infect immunocompromised patients including those with diabetes. Commonly attributed infections to Klebsiella pneumoniae include urinary tract infections (UTIs) and pneumonias. Rarely, incidence of abscess formation secondary to Klebsiella pneumonia infection has been reported in organ like liver, lung, and brain [1]. In addition, certain serotypes of Klebsiella pneumoniae, particularly K1 and K2, have been reported to involve secondary areas of the body through metastatic spread from the primary abscess [1–8]. Klebsiella liver abscess presenting as a widely metastatic invasive syndrome has been reported in South East Asia [1, 2]. However, only a few cases of renal abscess with metastatic spread have been reported [2–8]. In this report, we describe a rare case of Klebsiella pneumoniae renal abscess with metastatic lesions to the brain, eyes, and lungs. 2. Case Report A 41-year-old Hispanic female with a history of type 2 diabetes mellitus presented with four-to-five days of progressively worsening fever, headache, right eye pain, blurred vision, nausea, and vomiting. She also complained of shortness of breath and pleuritic chest pain over the last twenty four hours. On examination, a hypopyon was visualized in the anterior chamber of right eye, and bilateral crackles were heard on lung auscultation. No significant weakness or numbness was found on neurological exam. Complete blood count showed leukocytosis with neutrophilic predominance. Urine analysis was consistent with urinary tract infection. Her condition deteriorated at this point, and she became confused and disoriented. Cultures were obtained, and she was started on empiric intravenous antibiotics (Vancomycin and Zosyn). Ophthalmology service was consulted, and she was treated with intravitreal injection of vancomycin and ceftazidime. MRIs of her brain and orbits were obtained which showed inflammatory changes surrounding the right ocular globe, consistent with endopthalmitis (Figure 1(a)). There were also multifocal regions of increased
Imported Amoebic Liver Abscess in France  [PDF]
Hugues Cordel,Virginie Prendki,Yoann Madec,Sandrine Houze,Luc Paris,Patrice Bourée,Eric Caumes,Sophie Matheron,Olivier Bouchaud ,the ALA Study Group
PLOS Neglected Tropical Diseases , 2013, DOI: 10.1371/journal.pntd.0002333
Abstract: Background Worldwide, amoebic liver abscess (ALA) can be found in individuals in non-endemic areas, especially in foreign-born travelers. Methods We performed a retrospective analysis of ALA in patients admitted to French hospitals between 2002 and 2006. We compared imported ALA cases in European and foreign-born patients and assessed the factors associated with abscess size using a logistic regression model. Results We investigated 90 ALA cases. Patient median age was 41. The male:female ratio was 3.5:1. We were able to determine the origin for 75 patients: 38 were European-born and 37 foreign-born. With respect to clinical characteristics, no significant difference was observed between European and foreign-born patients except a longer lag time between the return to France after traveling abroad and the onset of symptoms for foreign-born. Factors associated with an abscess size of more than 69 mm were being male (OR = 11.25, p<0.01), aged more than 41 years old (OR = 3.63, p = 0.02) and being an immigrant (OR = 11.56, p = 0.03). Percutaneous aspiration was not based on initial abscess size but was carried out significantly more often on patients who were admitted to surgical units (OR = 10, p<0.01). The median time to abscess disappearance for 24 ALA was 7.5 months. Conclusions/Significance In this study on imported ALA was one of the largest worldwide in terms of the number of cases included males, older patients and foreign-born patients presented with larger abscesses, suggesting that hormonal and immunological factors may be involved in ALA physiopathology. The long lag time before developing ALA after returning to a non-endemic area must be highlighted to clinicians so that they will consider Entamoeba histolytica as a possible pathogen of liver abscesses more often.
Amoebic liver abscess: a diagnostic dilemma in the elderly
IB Bosan, TS Baduku
Annals of African Medicine , 2003,
Abstract: A 63-year old man presented with a 2-year history of progressive abdominal swelling with non-specific symptoms and signs. He visited several hospitals, where no diagnosis could be made for about 2 years and all therapeutic options given were ineffective. The appearance of an elevated right hemi diaphragm on chest X-ray, a single well defined area of Sonolucency with a thin edged border on ultrasound and a positive amoebic precipitin led to a diagnosis of amoebic liver abscess. Radiological intervention through ultrasound guided aspiration combined with medical therapy using metronidazole, led to rapid recovery and near complete resolution. This case typifies a not very uncommon but atypical presentation of amoebic liver abscess seen in practice characterized by intra abdominal space occupying lesion with non-specific symptoms and signs. Effective use of imaging techniques should help in the diagnosis. Ultrasound guided aspiration combined with medical therapy is effective treatment.
BRAIN ABSCESS
Zafar Iqbal
The Professional Medical Journal , 1999,
Abstract: A study of 50 cases of brain abscess is presented, emphasis being on clinical presentation and earlydiagnosis. A comparison is made with other studies and recommendations are made for early diagnosis.
Acute Pancreatitis Associated with Amoebic Liver Abscess  [PDF]
Jayant Kumar Ghosh,Vinod Kumar Dixit,Sangey Chopel Lamtha,Sundeep Kumar Goyal,Pankaj Kaushik
Case Reports in Gastrointestinal Medicine , 2013, DOI: 10.1155/2013/717393
Abstract: We present a rare case of acute pancreatitis in a 50-year-old man with amoebic liver abscess. He had a right lobe liver abscess along with markedly elevated serum lipase and amylase levels and edematous pancreas. Liver abscess was aspirated. The patient was managed conservatively with antibiotics and improved without any complications. Acute pancreatitis associated with ALA is not reported in the literature till date. 1. Case Report A 50-year-old male, nonalcoholic, presented with pain in right upper abdomen for the last 7 days which had increased in severity in the last 24 hours. He had not passed flatus for the last 12 hours. The patient had a history of acute diarrhea 1 month back. At admission patient was conscious, febrile and had diffuse upper abdominal pain which was severe in intensity. Abdomen was distended and bowel sounds were absent. There was tender hepatomegaly. Spleen was not palpable. No free fluid was detected clinically. There was no past history of diabetes, hypertension, and abdominal/biliary surgery. His investigations showed leukocytosis (total leukocyte count = 18,000/mm3). Serum lipase and amylase were markedly elevated (1788?mg/dL and 1365?mg/dL, resp.). X-ray abdomen showed distended bowel loops. Ultrasonography (USG) of abdomen was done which revealed an abscess cavity of 8 × 8 × 7?cm3 in the right lobe of liver situated near the surface of the liver. Serum IgG Entamoeba histolytica was positive. No gall bladder or common bile duct stones were seen in the USG. He had mild hypocalcaemia (serum calcium level = 8.2?mg/dL). Serum lipid profile, glucose, liver function tests, renal function tests, and thyroid profile were within normal limit. X-ray chest was unremarkable except for prominent bronchovascular markings. Arterial blood gas analysis was almost normal except for low calcium level. On day 2 of hospital admission, contrast enhanced CT (CECT) scan of abdomen was done which showed a large right lobe liver abscess associated with edematous pancreas without any necrosis or acute fluid collections (Figure 1). The modified CT severity index (CTSI) was 4/10. No fistulous communication between liver and pancreas or other organs could be demonstrated in the CECT abdomen. Patient was managed with intravenous fluid, intravenous antibiotics, that is, metronidazole and meropenem. Liver abscess was aspirated under USG guidance and about 250?mL of anchovy sauce pus was aspirated. Gram stain and culture of the pus were negative. The pus was also examined for pancreatic enzymes which were within normal limits. On day 2 of hospitalization
Standardization and evaluation of ELISA for the serodiagnosis of amoebic liver abscess
Nicholls, R. Santiago;Restrepo, Marcos I.;Duque, Sofia;Lopez, M. Consuelo;Corredor, Augusto;
Memórias do Instituto Oswaldo Cruz , 1994, DOI: 10.1590/S0074-02761994000100010
Abstract: an elisa test for the serological diagnosisof amoebic liver abscess (ala) was standardized and evaluated in sera from three groups of patients: (1) three patients with diagnosis confirmed by isolation of the parasite,(2) thirty seven patients with diagnosis established by clinical findings and ultrasound studies and (3) seven patients whose diagnosis were established by clinical findings and a positive double immunodifusion test. ninety one serum samples from healthy subjects and 22 from patients with other liver or parasitic diseases were also included in the study. the optimum concentration of entamoeba histolytica antigen was 1.25 μg/ml and optimum dilutions of serum and anti-human igg-alkaline phosphatase conjugate were 1:400 and 1:4000 respectively. the cut-off point of the elisa test in this study was an absorbance value of 0.34. the test parameters were: sensitivity = 95.7 per cent, specificty = 100 per cent, positive predictive value = 100 per cent and negative predictive value = 98.2 per cent.the elisa test was found to be of great use as a diagnostic tool for the establishment of amoebic etiology in patients with clinical supposition of ala. the test could also be used for seroepidemiological surveys of the prevalence of invasive amoebiasis in a given population, since it allows the processing of a greater number of samples at a lower cost tahn other serological tests.
Detection of excretory Entamoeba histolytica DNA in the urine, and detection of E. histolytica DNA and lectin antigen in the liver abscess pus for the diagnosis of amoebic liver abscess
Subhash C Parija, Krishna Khairnar
BMC Microbiology , 2007, DOI: 10.1186/1471-2180-7-41
Abstract: E. histolytica DNA was detected in liver abscess pus specimen of 80.4% of ALA patients by a nested multiplex polymerase chain reaction (PCR) targeting 16S-like r RNA gene. The nested PCR detected E. histolytica DNA in all 37 (100%) liver abscess pus specimens collected prior to metronidazole treatment, but were detected in only 53 of 75 (70.6%) pus specimens collected after therapy with metronidazole. Similarly, the PCR detected E. histolytica DNA in 21 of 53 (39.6%) urine specimens of ALA patients. The test detected E. histolytica DNA in only 4 of 23 (17.4%) urine specimens collected prior to metronidazole treatment, but were detected in 17 of 30 (56.7%) urine specimens collected after treatment with metronidazole. The enzyme-linked immunosorbent assay (ELISA) for the detection of lectin E. histolytica antigen in the liver abscess pus showed a sensitivity of 50% and the indirect haemagglutination (IHA) test for detection of amoebic antibodies in the serum showed a sensitivity of 76.8% for the diagnosis of the ALA.The present study for the first time shows that the kidney barrier in ALA patients is permeable to E. histolytica DNA molecule resulting in excretion of E. histolytica DNA in urine which can be detected by PCR. The study also shows that the PCR for detection of E. histolytica DNA in urine of patients with ALA can also be used as a prognostic marker to assess the course of the diseases following therapy by metronidazole. The detection of E. histolytica DNA in urine specimen of ALA patients provides a new approach for the diagnosis of ALA.Infection with Entamoeba histolytica, results in 34 million to 50 million symptomatic cases of amoebiasis worldwide each year, causing 40 to 100 thousand deaths annually [1]. Mortality from amoebiasis is mainly due to extra-intestinal pathology, of which amoebic liver abscess (ALA) is the most common. If left untreated, ALA can rupture into neighboring tissue and spread to the brain and other organs via hematological route
Amoebic liver abscess in the medical emergency of a North Indian hospital
Navneet Sharma, Aman Sharma, Subhash Varma, Anupam Lal, Virendra Singh
BMC Research Notes , 2010, DOI: 10.1186/1756-0500-3-21
Abstract: The mean age of patients was 40.5 ± 2.1 years (male-female ratio = 7:1). Fever, pain abdomen and diarrhea were seen in 94%, 90% and 10.5% respectively. Duration of symptoms less than 2 weeks was seen in 48% cases. Hepatomegaly was present in 16% cases only, a right sided pleural effusion in 14% cases and ascites in 5.7%. On ultrasound, a right lobe abscess was seen in 65%, a left lobe abscess in 13% and multiple abscesses in both the lobes in 22% cases. Seventy one cases underwent per-cutaneous pigtail catheter drainage for a mean period of 13.4 ± 0.8 days. The mortality rate was 5.8%. On multivariate regression and correlation analysis, a higher number of inserted pigtail catheters correlated to mortality.Amoebic liver abscess presents commonly to the emergency department and should be suspected in persons with prolonged fever and pain abdomen. Conservative management for uncomplicated amoebic liver abscess and insertion of single per-cutaneous pigtail catheter drainage for complicated amoebic liver abscess are efficacious as treatment modalities.Diseases caused by Entamoeba histolytica manifest as acute infectious diarrhea clinically and pathologically as ulcerative and inflammatory lesion in the caecum and the entire colon [1]. The organism during the invasive stage gains access to the liver via the portal vein where marked tissue destruction occurs resulting in a liver abscess [2-7]. In India, due to poor sanitary condition and a lower socioeconomic status, amoebiasis is endemic and amoebic liver abscess accounts for 3-9% of all cases of amoebiasis [8].Patients with amoebic liver abscess manifest early with abdominal pain and fever or as fever of unknown origin, weight loss and abdominal pain [7]. Coexisting diarrhea occurs in 30% and it is extremely rare to find amoebic trophozoites in the stool examination [7]. Although, amebic liver abscess occurs mostly in the right lobe, yet, considerable variations exist. In an ultrasonographic analysis of 212 patients of
Evaluation of antigen detection and polymerase chain reaction for diagnosis of amoebic liver abscess in patients on anti-amoebic treatment
Virendra Jaiswal, Ujjala Ghoshal, Sanjay S Baijal, Balraj Mittal, Tapan N Dhole, Uday C Ghoshal
BMC Research Notes , 2012, DOI: 10.1186/1756-0500-5-416
Abstract: Using anti-amoebic IgG antibody and bacterial culture, 136/200 (68.0%) were classified as ALA, 12/200 (6.0%) as pyogenic liver abscess (PLA), 29/200 (14.5%) as mixed infection, and 23/200 (11.5%) remained unclassified. Using amoebic PCR and bacterial culture 151/200 (75.5%) were classified as ALA, 25/200 (12.5%) as PLA, 16/200 (8.0%) as mixed infection, and 8/200 (4.0%) remained unclassified. With E. histolytica lectin antigen and bacterial culture, 22/200 (11.0%) patients were classified as ALA, 39/200 (19.5%) as PLA, 2/200 (1.0%) as mixed infection, and 137/200 (68.5%) remained unclassified.E. histolytica lectin antigen was not suitable for classification of ALA patients who had prior anti-amoebic treatment. However, PCR may be used as alternative test to anti-amoebic antibody in diagnosis of ALA.Amoebic liver abscess (ALA) is caused by protozoan parasite Entamoeba histolytica (E. histolytica), a common parasitic infection in tropical countries [1-3]. Approximately 50 million people are infected with E. histolytica annually world-wide, with mortality ranging from 40,000 to 1,000,00 [4]. Most of the mortality due to amoebiasis results from hepatic rather than intestinal infection. Clinical and radiological features of ALA are often somewhat similar with pyogenic liver abscess (PLA). Hence, necessitating laboratory investigation for differentiation between ALA and PLA are required [5]. Currently ALA is distinguished from PLA by microscopic examination, anti-amoebic IgG serology, and culture of aspirate for pyogenic organisms.Detection of trophozoites on microscopic examination in liver aspirate, though confirmatory of ALA, is quite insensitive [6,7]. Diagnosis of ALA is most frequently made using serum anti-amoebic IgG antibody [8,9]. However, this assay may not distinguish past from current infection, especially in endemic regions [10]. Thus, anti-amoebic IgG antibody may also be detected in a proportion of healthy people [10,11].Sensitivity and specificity of E. h
Amoebic liver abscess — results of a conservative management policy
PI McGarr, TE Madiba, SR Thomson, P Corr
South African Medical Journal , 2003,
Abstract: Objective. To evaluate the safety and efficacy of conservative management of amoebic liver abscesses. Design. A prospective study carried out over a 1-year period. Setting. Inpatients and outpatients in a tertiary referral institution. Subjects. Amoebic liver abscess was diagnosed on clinical, ultrasonographic, and serological features. All patients were treated with metronidazole. The indication for ultrasoundguided aspiration of the abscess was failure to improve clinically within 48 - 72 hours. Main outcome measures. Clinical improvement, clinical deterioration and failure of clinical improvement (persistent pain). Results. In total 178 patients (male-to-female ratio 5:1) with 203 abscesses were treated during this period. Of these, 23 patients required percutaneous aspiration and 150 patients were managed without intervention and clinically resolved spontaneously. Abscesses requiring aspiration tended to be larger than those managed without aspiration (10.7 cm v. 8.2 cm) (p = 0.003). There were no complications following aspiration. Mean hospital stay was longer (12.3 days) for patients who underwent aspiration compared with those who did not (6. 7 days) (p = 0.031). Only 5 patients presented with ruptured abscesses, 1 cutaneously and 4 intraperitoneally, with the only death in this latter category. Conclusion Conservative medical management of amoebic liver abscess is safe. Percutaneous ultrasound-guided aspiration is indicated only in patients who fail to improve clinically after 48 - 72 hours rather than on rigid criteria.
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