Value of punch biopsy in diagnosis of palpable breast tumors. A prospective analysis of 150 patients

A 65-year-old female received recombinant interferon (IFN) alpha-2b daily for the treatment of chronic hepatitis C. Fever (39 degrees C or higher) developed 14 days after the start of administration. Abdominal computed tomography suggested multiple liver abscesses, which had not been detected before IFN administration. An autopsy revealed an amoebic liver abscess. A subclinical infection of Entamoeba histolytica in this case developed into amoebic liver abscess during IFN administration.     

Conservative initial treatment for liver abscesses in children

A total of 124 children aged less than 14 years with a liver abscess were seen in a 16-year period (1974-1990) and treated by non-operative initial management. Of the abscesses 98 occurred in the right liver and 26 in the left. The abscesses were solitary in 93 patients. Overall, 77 of the solitary and 21 of the multiple abscesses were confined to the right liver. In 78 of the right-sided and 20 of the left-sided abscesses the infection was primarily pyogenic in nature with Staphylococcus aureus being the usual organism cultured. The remainder were of amoebic origin. Clinical features were similar in patients with amoebic and pyogenic abscesses. Clinical and ultrasonographic follow-up demonstrated successful non-operative management and healing in 37 per cent of all patients submitted to an initial protocol of medical supportive care and antibiotic therapy. Of the multiple abscesses 60 per cent responded to non-operative management. Fourteen of the 16 solitary left-sided liver abscesses required drainage and three left-sided abscesses ruptured before drainage. Patients with a solitary left-sided abscess warrant early operative intervention.     

Tropical liver abscess

Forty-one consecutive cases of liver abscesses seen at the National University Hospital, Singapore from 1988 to 1994 were reviewed. Twenty-seven cases (65%) were pyogenic, six (15%) amoebic, two (5%) tuberculous and six (15%) indeterminate. The predominance of pyogenic abscesses is in marked contrast to previous studies from the region a decade ago in which amoebic abscesses were the commonest type. The commonest pathogen causing pyogenic abscess was Klebsiella pneumoniae. Two cases were due to Mycobacterium tuberculosis, and this organism needs to be actively looked for in smears and cultures of aspirated material. As the majority of organisms isolated were resistant to ampicillin, empirical antibiotic treatment for suspected pyogenic abscess should include gentamicin or a cephalosporin. Percutaneous needle aspiration of the abscess was performed for 85% of pyogenic abscesses and surgery was necessary in only two cases because of complications. We found that percutaneous aspiration of liver abscess is helpful to confirm the diagnosis, provides a better bacteriological culture yield, gives a good outcome, and may uncover clinically unsuspected conditions like malignancy and tuberculoma which may mimic the presentation of liver abscesses. We recommend routine cytological examination of aspirated abscess material as well as stains and cultures for acid-fast bacilli.     

Granulomatous hepatitis: a retrospective study

51 cases of granulomatous hepatitis were seen among 1234 liver biopsies over a 10 year period. Tuberculosis was the commonest cause seen in 55 percent of cases. Other causes included leprosy, sarcoidosis, histoplasmosis, brucellosis, amoebic liver abscess, lymphoma and malignant granuloma. 12 percent of cases remained undiagnosed. Clinically these patients presented with pyrexia and hepatosplenomegaly. Jaundice was uncommon. Many showed elevated alkaline phosphatase levels, anaemia and raised ESR Granulomatous hepatitis of unknown aetiology with FUO was seen in 6 percent cases only.     

Therapeutic approach to hepatic abscesses

Thirty-five patients with hepatic abscesses were treated at our institution during an 8-year period. Twenty-nine patients had bacterial abscesses, and six patients had amoebic abscesses. The patients were admitted with fever (95%), right upper quadrant pain (63%), and nausea and vomiting (40%) as the most common symptoms. Eleven patients had some inciting cause for the abscess formation; the remaining 18 bacterial abscesses were cryptogenic. The primary abnormal test results were leukocytosis (91%) and liver enzyme elevations (80%). All patients with amoebic abscesses were serologically positive for amoebic infection. Computed tomography (CT) was the most effective imaging modality for diagnosis. Twenty patients were treated with open surgical drainage, 11 with percutaneous drainage, and 4 with antibiotics alone. Three of the four latter patients had amoebic abscesses. Abscesses in two patients initially treated with percutaneous drainage did not resolve, and the patients ultimately required surgery. The remaining indications for surgery were concomitant conditions requiring surgical intervention or inaccessibility of the abscess to percutaneous drainage. Antibiotics were given to all patients, with treatment duration from 10 to 60 days. The hospital mortality was 6% due to sepsis and a postoperative myocardial infarction in one patient, and perioperative myocardial infarction in another; overall morbidity was 20%. At a mean follow-up of 13 months, all surviving patients had resolution of the abscess shown by either CT (11 patients) or clinical examination (22 patients). We conclude that effective drainage, whether it be surgical or percutaneous, and appropriate antibiotic coverage are the mainstays of therapy for hepatic abscesses.     

Cyclosporine-related encephalopathy following allogeneic bone marrow transplantation

Idiopathic granulomatous hepatitis is a rare disease of unknown cause that is characterized by recurrent fevers and granuloma in the liver. Attempts to define an exact etiology of the fever of granulomatous hepatitis frequently do not yield a precise diagnosis. Idiopathic granulomatous hepatitis was confirmed after a thorough work up and negative cultures and serologies were obtained, and in the absence of another condition that could lead to granulomas in the liver. We have experienced a 67-year-old female patient who presented with prolonged fever for 2 months and revealed granuloma in liver biopsy. She was treated with glucocorticosteroid and defervescence resulted.     

Spread of the serotype 23F multidrug-resistant Streptococcus pneumoniae clone to South Korea

We report the case of 61-year-old woman with cryptogenic liver abscesses who had been profoundly ill with severe upper abdominal pain, impaired consciousness, prostration, continuous high fever secondary to sepsis, and thrombocytopenia (platelets, 1-5 x 10(4)/mm3) since admission. Ultrasonograms and computed tomograms revealed two separate multiloculated lesions in the right lobe of the liver, consistent with the liver abscesses. Immediately after diagnosis, percutaneous abscess drainage was performed under ultrasonographic guidance; however, only a small amount of pus was drained, prompting continuous irrigation of the abscess cavity. Four days later, transcatheter hepatic arterial infusion of antibiotics was attempted. However, the abscesses had enlarged and her general condition had worsened. On hospital day 8, she underwent right hepatectomy because the multiloculated lesions were refractory to drainage. The operation was successful in terms of hepatectomy, although she continued to suffer from sepsis, secondary right subphrenic abscess formation, and prolonged thrombocytopenia with associated coagulation disorders for two months. Examination of multiple cross sections of the resected specimen disclosed that the lesions consisted of aggregations of multiple small locules. There was no communication between the locules and there were true septations, rather than multiloculated lesions with pseudoseptations. The patient has been well for 2 years without recurrent abscess of the liver or any infectious disease.     

Hypertrophic cranial pachymeningitis with spinal epidural granulomatous lesion

A 67-year-old woman with a one-year history of tinnitus and headache had multiple cranial nerve palsies of V, VII, VIII, IX, X, XI and spastic paraparesis. She also had a secretory otitis media. Gd-DTPA-enhanced magnetic resonance imaging (MRI) revealed hypertrophy of the dura of the posterior fossa and spinal epidural mass which extended from C7 to T10. A biopsy of the epidural mass showed chronic granulomatous change. These lesions were completely cured with administration of antibiotics. We believe this case of double-lesion of hypertrophic cranial pachymeningitis and spinal epidural granulomatous lesion originated from a bacterial infection secondary to the secretory otitis media.     

Inhibitors of mitochondrial energy production prevent DNA internucleosomal fragmentation in thymocytes

We describe a case of multiple hepatic pyogenic abscesses with an unusual presentation. The typical signs and symptoms of fever and pain in the right upper quadrant were absent. Instead, the chief complaint was muscle weakness and myalgias accompanied by weight loss. Findings from an ultrasonogram of the abdomen revealed multiple hepatic lesions consistent with metastases. Hence, the initial presumptive diagnosis was metastatic malignancy with unknown primary tumor. It was only when purulent material was unexpectedly encountered when a needle biopsy was performed that the true diagnosis of pyogenic liver abscess was recognized. While liver abscess is rare, it should not be forgotten in the differential diagnosis for multiple hepatic lesions seen on imaging studies.     

Actinomycotic brain abscess

Actinomycosis is a chronic, suppurative and granulomatous bacterial infection, which tends to form abscesses. Involvement of the central nervous system (CNS) is rare. We describe the clinical and neuroradiological findings of four patients (3 men and one female) diagnosed of actinomycotic brain abscesses. Risk factors were dental pathology, intrauterine device use, alcohol abuse and Rendu-Osler-Weber disease. Clinical manifestations were those of a space-occupying lesion. CT scan findings were varied and little specific: hemispheric or periventricular location, pyocephalus, rim-enhancing and edema. MRI was superior in disclosing pyocephalus. Diagnosis was performed by microbiological and pathological findings. Despite surgery and antibiotics, two of the patients died. In conclusion, the infection of the CNS by Actinomyces is potentially fatal and should be considered in those patients with cerebral abscess.     

Improvement of respiratory burst by individual neutrophils from a patient with chronic granulomatous disease, type X91- under treatment by granulocyte colony-stimulating factor for multiple liver abscess

A 20-year-old male with chronic granulomatous disease (CGD) was admitted with multiple liver abscesses. He had already been diagnosed as CGD, type X91-, when he was 10 years old. He was successfully treated with antibiotics and granulocyte colony-stimulating factor (G-CSF) combined with continuous drainage of abscess. Employing flow cytometry, respiratory burst by individual neutrophils was measured using 2', 7'-dichlorofluorescein. The fluorescence intensity in all individual neutrophils from the patient under G-CSF treatment was higher than the one without G-CSF. G-CSF can be one of effective therapies for infection in some patients with CGD such as X91-.     

Pseudotumor form of hepatic distomatosis: successful treatment with praziquantel

Human Fasciola hepatica infection is usually discovered either early, during the acute (invasive) phase, or in the advanced phase, which is characterized by biliary complications. We report a case of liver distomatosis with nodular intra-hepatic lesions in a 58-year-old woman. Radiological investigations showed 3 nodular lesions in the VII segment, which were difficult to distinguish from liver metastases or liver abscesses. Distomatosis serology was positive with passive hemagglutination. After a 5-day treatment with praziquantel, clinical symptoms resolved quickly while serological tests became negative. Radiological images slowly decreased to a calcified scar at 13 months. No side-effects were noted. Praziquantel, whose efficacy in the common presentations of liver distomatosis has recently been demonstrated, also seems effective and well tolerated in case of nodular intra-hepatic lesions.     

Portal vein thrombosis and multiple liver abscesses in Crohn's disease--an example for successful conservative treatment

We report about a 27-year-old patient with Crohn's disease presenting with two complications; Portal vein thrombosis and multiple liver abscesses. Conservative treatment with antibiotics and percutaneous catheter drainage was successful, the liver abscesses disappeared. 18 months later the patient presented in best condition. Ultrasound showed cavernous transformation of the portal vein system and splenomegaly, discrete esophageal varices were seen by esophagogastroscopy. This is an example for an excellent course under conservative therapy of liver abscesses, on the other hand it is the first reported case of a patient with a combination of portal vein thrombosis and multiple liver abscesses in Crohn's disease.     

Central nervous system lesions in liver transplant recipients: prospective assessment of indications for biopsy and implications for management

BACKGROUND: Precise diagnosis of central nervous system (CNS) lesions in liver transplant recipients remains problematic. Brain biopsies are often not feasible as a result of coagulopathy. We sought to determine whether selected clinical or radiologic characteristics can predict the likely etiology of CNS lesions in liver transplant recipients and thus obviate the need for diagnostic brain biopsies. METHODS: A 4-year prospective, observational, cohort study was conducted at liver transplant centers at four geographically diverse medical institutions. A total of 1730 consecutive liver transplant recipients were evaluated for CNS lesions; 60 patients with radiologically documented CNS lesions comprised the study sample. RESULTS: Vascular events (52%, 31/60), infections (181%, 11/60), immunosuppressive associated leukoencephalopathy (12%, 7/60), central pontine myelinolysis (8%, 5/60), and malignancy (3%, 2/60) were the predominant etiologies of CNS lesions. CNS lesions were most likely to occur within 30 days of transplantation (43%, 26/60); central pontine myelinolysis, subdural hematoma, acute infarcts, and Aspergillus brain abscesses were the predominant etiologies during this time. All brain abscesses were fungal; 73% (8/11) of these patients concurrently had documented extraneural (pulmonary) infection as a result of the same fungal pathogen. Thus, a diagnostic brain biopsy is not warranted in these patients. Patients on dialysis were more likely to have ischemic or infectious CNS lesions (P=0.03). Vascular events were more likely to occur in repeat transplant recipients (P=0.03). Twenty-five percent (15/60) of the CNS lesions occurred more than 1 year after transplantation; small vessel ischemic lesions, malignancy, or non-Aspergillus fungal brain abscesses accounted for all such lesions. CONCLUSIONS: A presumptive etiologic diagnosis can be established in a vast majority of CNS lesions in liver transplant recipients based on identifiable presentation that includes time of onset, unique risk factors, and neuroimaging characteristics. Empiric therapy of brain abscesses in liver transplant recipients should include antifungal and not antibacterial agents.     

Nocardia abscess of the choroid plexus: clinical and pathological case report

OBJECTIVE: Cerebral Nocardia abscesses are rare, accounting for approximately 1 to 2% of all cerebral abscesses. Prompt aggressive surgical treatment involving craniotomy and excision of these lesions has been advocated by many authors, because these lesions have significantly higher morbidity and mortality rates than do most other cerebral abscesses. We report an atypical presentation of cerebral nocardiosis localized to the choroid plexus of the lateral ventricle. CLINICAL PRESENTATION: A 56-year-old man presented with a 3-week history of fever, cough, and progressive headache and an ensuing 3-day history of progressive lethargy, confusion, and gait ataxia. Radiographic studies demonstrated a loculated contrast-enhancing left lateral ventricular lesion with significant perilesional parenchymal edema that was thought preoperatively to be a neoplasm. INTERVENTION: The patient underwent a craniotomy for resection of the lesion. Intraoperatively, a reddish gray lesion with purulent exudate was encountered within the left lateral ventricle intimately adherent to the choroid plexus as well as to the ependyma and subependymal veins. A frozen section demonstrated an organizing abscess wall. The lesion was resected in its entirety, and multiple cultures were sent for analysis. CONCLUSION: Microbiology cultures grew Nocardia asteroides. A course of intravenous antibiotics was started, which included trimethoprim-sulfamethoxazole, amikacin, and ceftriaxone. Two weeks after surgery, at the time of discharge, the patient's neurological status had improved considerably. Although Nocardia abscesses have been documented to occur throughout the central nervous system, the presentation of a lesion confined to the choroid plexus of the lateral ventricle with significant parenchymal edema is unusual and demonstrates that Nocardia abscesses must be considered in the differential diagnosis of a contrast-enhancing intraventricular mass lesion involving the choroid plexus.     

Relation between laboratory test results and histological hepatitis activity in individuals positive for hepatitis B surface antigen and antibodies to hepatitis B e antigen

BACKGROUND: Hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B e antigen (anti-HBe) commonly coexist, and laboratory tests are often requested to assess histological hepatitis activity. An optimum panel of tests has not been found and the usefulness of hepatitis B virus (HBV) DNA assays in this context has not been established. We assessed various blood tests to find which best predicted hepatitis activity. METHODS: Routine plasma biochemical liver tests and serum HBV DNA (hybridisation and PCR assays) were assessed prospectively in 123 patients positive for HBsAg and anti-HBe. We scored histological hepatitis activity (hepatitis activity index) and determined whether chronic active hepatitis (chronic hepatitis with portal and periportal lesions) was present. We analysed the relation between laboratory data and the hepatitis activity index or risk of chronic active hepatitis by multiple regression and multiple logistic regression, respectively. FINDINGS: The analyses provided models for predicting either the hepatitis activity index or the risk of chronic active hepatitis. Aspartate aminotransferase was the most important test in the two models. The contribution of HBV DNA and other assays, especially alanine-aminotransferase activity, were of no practical importance. INTERPRETATION: Because screening by aspartate-aminotransferase activity could not be improved by the addition of other assays or HBV DNA, patients positive for HBsAg and anti-HBe could be screened for chronic active hepatitis with a single assay and counselling of patients can be improved if proper reference values are used.     

Parasitic amoebae and amoebo-flagellates from the Lobosea and heterolobosea classes

Different cited evidences on parasitic amoebae and amoebo-flagellates belonging to the Lobosea and Heterolobosea classes (Pages, 1987) have been reviewed. Special attention is paid to various degree of their adaptation to parasitic mode of life, which ranges from a parasitism on a border with commensalism to true parasitism (both facultative and obligatory ones). Besides the coprophilous and commensal species, the number of true parasites among the Lobosea and Heterolobosea classes is comparatively small. In many cases, both facultative and obligatory parasites cause the death of their hosts. Apparently this strongly pronounced pathogenicity of parasitic amoebae and amoebo-flagellates suggest a recent origin of such parasite-host systems. Pathogens of amoebic dysentry, primary amoebic meningoencephalitis and granulomatous amoebic encephalitis are specially considered. In the Russian text-books on a parasitology the information on most of them, except Entamoeba hystolytica, is either totally absent or very scare and out of date.     

Resolution of focal fatty infiltration of the liver

Focal fatty infiltration of the liver has been recognized as a distinct entity only since 1980. It may simulate neoplastic or other low-density parenchymal lesions, including abscesses and hemangiomas. I report a case of histologically confirmed focal fatty infiltration of the liver in a man with obesity and alcoholism; the lesion disappeared after the patient began a program of exercise, weight loss, and abstinence from alcohol. The possible pathogenesis of focal fatty infiltration of the liver is reviewed, diagnostic techniques are described, and reversibility of the lesion is discussed.     

Liver abscess secondary to intrahepatic perforation of the gallbladder, presenting as a liver mass

We present an unusual case of a large pyogenic liver abscess containing multiple stones caused by perforation of a necrotic gallbladder and spread of the infection into the liver. It manifested by weakness, weight loss, and a palpable liver mass, pointing toward a neoplastic process. Workup for metastatic disease was negative, and tumor markers also were negative. Ultrasound and computerized tomography were inconclusive, and the diagnosis was established by laparoscopy. Open drainage and cholecystectomy were performed, with good outcome. In the literature, there have been very few reports of intrahepatic perforation of the gallbladder resulting in formation of hepatic abscess. The presentation, diagnosis, and management of liver abscesses, as well as the complications of acute cholecystitis, are discussed.     

Granulomatous hepatitis attributed to the combination pyrimethamine-chloroquine

After her holiday in South Africa, a 50-year-old woman was admitted because of fever and pain in the upper abdomen. The laboratory tests showed moderately increased serum liver enzyme activities. The liver biopsy showed a granulomatous hepatitis. Further investigations revealed no evidence for sarcoidosis, tuberculosis or infectious hepatitis, nor for other granulomatous diseases or infectious diseases relevant to South Africa. Upon discontinuation of the malaria prophylaxis with Daraclor (pyrimethamine and chloroquine (sulphate)) the symptoms disappeared and the liver function tests returned to normal. It was concluded that Daraclor was the probable cause of granulomatous hepatitis in this patient. This adverse effect was not published before.