Microbiology and Management of Pediatric Liver Abscesses: Two Cases Caused by Streptococcus anginosus Group

Pyogenic liver abscesses in the pediatric population are rare occurrences in the developed world. We present two cases of previously healthy males presenting with fever and abdominal pain found to have liver abscesses due to organisms in the Streptococcus anginosus group. The microbiology of S. anginosus along with the management and recommended treatment in children with liver abscesses is discussed. 1. Case 1 DK is a 16-year-old male presenting with severe abdominal pain. Three days prior while playing baseball, DK slid and began complaining of chest pain. Three days later he developed fever to 102°F and chills. His vital signs on presentation were blood pressure 102/71, pulse 108？bpm, respirations 16？bpm, and temperature 39.2°C. He was awake, tired, and flushed appearing. He had pain along his ribs on the lower right side of his abdomen along with decreased bowel sounds and tenderness of the right upper quadrant with voluntary guarding. There was no hepatosplenomegaly or masses. Labs included a disseminated intravascular coagulation (DIC) profile which showed fibrinogen 766 and a CBC showing WBC 13.6, HgB 12.7, Hct 35, platelets of 386 with 76% neutrophils, 15% lymphocytes, and 8% monocytes. Liver function testing was normal. He had a negative monospot, a normal amylase and lipase, an erythrocyte sedimentation rate (ESR) of 97？mm/hr, and a c-reactive protein (CRP) of 37.1？mg/dL. An ultrasound of the abdomen revealed a hypoechoic mass within the anterolateral right hepatic lobe further delineated by CT (Figure 1(a)) which revealed an abscess. He was placed on intravenous Piperacillin/Tazobactam followed by percutaneous drainage. Culture revealed 2+ Streptococcus intermedius (viridians strep). DK had serial CRPs which improved. A repeat ultrasound showed no lesion and the drain was removed. He was discharged home on intravenous Clindamycin; however, five days later he became febrile and returned to the emergency room. He had a WBC 17.7 with 85% neutrophils, a mild transaminitis, and a CRP of 5.8？mg/dL. An ultrasound of his abdomen revealed ？cm fluid collection. He was taken to interventional radiology for repeat aspiration and replacement of drain. A follow-up ultrasound showed a persistent hypoechoic area adjacent to the drain consistent with hematoma so the drain was capped. Repeat ultrasound remained unchanged and the drain was removed. Inflammatory markers continued to decline and he was discharged home on intravenous ampicillin. Figure 1: (a) Cystic lesion in the inferior right lobe of the liver that was rim enhancing and diffuse surrounding