Amoebic Liver Abscess Research Articles

Comparative Incidence of Pyogenic and Amoebic Liver Abscesses in Trauma and Emergency Patients at Indira Gandhi Institute of Medical Sciences (IGIMS), Patna: A One-Year Observational Study.

Liver abscesses, particularly pyogenic and amoebic types, pose a significant healthcare challenge, especially in developing countries. Accurate differentiation and effective treatment of these abscess types are crucial in emergency medical settings. This study aims to analyze the incidence, clinical characteristics, and treatment outcomes of pyogenic and amoebic liver abscesses in a trauma and emergency department setting. Conducted at the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, this one-year observational study involved 100 patients diagnosed with liver abscesses. The study employed a comprehensive approach, examining incidence rates, demographic trends, clinical presentations, treatment modalities, and outcomes, including recurrence rates. The study observed a higher incidence of pyogenic liver abscesses, accounting for 60% of cases (n=60), compared to amoebic liver abscesses, which constituted 40% (n=40). In terms of demographics, pyogenic liver abscesses were more prevalent among older males, with the average age being 48 years, and 70% (n=42) of the patients were male. In contrast, amoebic liver abscess patients had an average age of 42 years, with 60% (n=24) being male. Key clinical findings revealed that pyogenic liver abscess cases (n=60) had higher white blood cell counts and elevated liver enzyme levels than those with amoebic liver abscesses (n=40). The treatment outcomes indicated high success rates for both types of liver abscesses. Pyogenic liver abscesses had a success rate of 90% (n=54), while amoebic liver abscesses showed a slightly higher success rate at 95% (n=38). However, there was a notable difference in recurrence rates: pyogenic liver abscesses had a recurrence rate of 8.3% (n=5), whereas amoebic liver abscesses had a lower recurrence rate of 2.5% (n=1). The logistic regression analysis conducted to identify potential predictors of treatment success did not reveal any statistically significant factors across both types of liver abscesses. The study highlights a higher incidence of pyogenic liver abscesses in an urban Indian healthcare setting and the complexity of predicting treatment outcomes based on demographic and clinical factors. The findings emphasize the need for nuanced clinical approaches and vigilant post-treatment monitoring, especially for pyogenic liver abscesses. They also underscore the importance of further research to explore additional variables influencing liver abscess treatment outcomes.

Clinical Profile in Patients of Amoebic Liver Abscess with and without Hyperbilirubinemia: A Prospective Cohort Study

Introduction: In tropical countries like India, two-thirds of liver abscess cases are amoebic. Along with abdominal pain, fever, and other non-specific clinical features, jaundice is commonly observed in Amoebic Liver Abscess (ALA) cases. However, the understanding of jaundice in a patients with ALA is limited, and it is associated with a poor prognosis. Aim: To compare the morbidity and mortality of ALA patients with and without hyperbilirubinemia, as well as their clinical outcomes. Materials and Methods: The present prospective cohort study was conducted at a tertiary teaching institute in northern India. It included 150 patients aged between 20 and 60 years with a confirmed diagnosis of ALA. The patients were divided into two groups based on the presence or absence of hyperbilirubinemia. Those with jaundice resulting from other causes or a history of hepatitis were excluded. Variables examined in the study included age, sex, alcohol intake, basic laboratory parameters, ultrasound-assessed abscess size and number, and duration of hospital stay. Results: Among the 150 cases, 22 (14.6%) had elevated serum bilirubin levels (>1 mg/dL). Additionally, 122 (81.33%) had a history of alcohol intake, and 117 (78%) had a single abscess cavity. In ALA patients with hyperbilirubinemia, 12 (54.55%) had abnormal creatinine values, and 6 (27.26%) experienced complications such as rupture and peritonitis. One mortality occurred in a patient with ALA and jaundice. Conclusion: ALA patients with jaundice exhibited larger abscess cavities, a higher complication rates, a longer hospital stays, and a poor prognoses.

Amoebic Liver Abscess with Myocardial Involvement: An Emergency Perspective

Amoebic Liver Abscess with Myocardial Involvement: An Emergency Perspective

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

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

Genes differentially expressed between pathogenic and non-pathogenic Entamoeba histolytica clones influence pathogenicity-associated phenotypes by multiple mechanisms.

Recently, two genes involved in amoebic liver abscess formation in a mouse model were identified by their differential expression of non-pathogenic (A1np) and pathogenic (B2p) clones of the Entamoeba histolytica isolate HM:1-IMSS. While overexpression of a gene encoding the metallopeptidase EhMP8-2 reduces the virulence of the pathogenic clone B2p, overexpression of the gene ehi_127670 (ehhp127), encoding a hypothetical protein, increases the virulence of the non-pathogenic clone A1np, while silencing this gene in the pathogenic B2p reduces virulence. To understand the role of both molecules in determining the pathogenicity of E. histolytica, silencing, and overexpression transfectants were characterized in detail. Silencing of ehmp8-2, of the homologous gene ehmp8-1, or both in non-pathogenic A1np trophozoites significantly altered the transcript levels of 347, 216, and 58 genes, respectively. This strong change in the expression profiles caused by the silencing of ehmp8-1 and ehmp8-2 implies that these peptidases regulate the expression of numerous genes. Consequently, numerous phenotypic characteristics, including cytopathic, hemolytic, and cysteine peptidase activity, were altered in response to their silencing. Silencing of ehhp127 in pathogenic B2p trophozoites did not affect the expression of other genes, whereas its overexpression in non-pathogenic A1np trophozoites results in an altered expression of approximately 140 genes. EhHP127 is important for trophozoite motility, as its silencing reduces, while its overexpression enhances movement activity. Interestingly, the specific silencing of ehhp127 also significantly affects cytopathic, cysteine peptidase, and hemolytic activities. All three molecules characterized in this study, namely EhMP8-1, EhMP8-2, and EhHP127, are present in amoeba vesicles. The results show that ehmp8-2 and ehhp127 are not only differentially expressed between pathogenic and non-pathogenic amoebae, but that they also significantly affect amoeba pathogenicity-associated phenotypes by completely different mechanisms. This observation suggests that the regulation of amoeba pathogenicity is achieved by a complex network of molecular mechanisms rather than by single factors.

Current Management of Liver Abscess: A Narrative Review

Liver abscess can be divided into pyogenic and amoebic liver abscess. The common organisms that cause pyogenic liver abscess include Escherichia Coli, with amoebic liver abscess being caused by Entamoeba histolytica. The diagnosis is made by ultrasound, computerized tomography, and magnetic resonance imaging of the liver. The treatment can be divided into medical therapy which involves percutaneous drainage and intravenous antibiotics, and surgical therapy which includes surgical drainage either by open or laparoscopic surgery. Surgical drainage is indicated for patients who have failed medical therapy. We have conducted this review article to look at the current management of liver abscess with regards to the role of percutaneous drainage and surgical drainage.

Novel diagnostic approach for amoebic liver abscess using cell free (cf) DNA: a prospective study

Background Amoebic liver abscess (ALA) is commonly seen in tropical countries and diagnosis of ALA relies mainly on non-specific serological and imaging techniques as well as PCR from pus. Objective This study evaluated the potential of using cell free DNA (cfDNA) from serum and urine for diagnosing ALA. Methods We prospectively evaluated quantitative PCR (qPCR) for detection of cf DNA in serum and urine sample in all liver abscess patients. The samples were collected from patients reporting to emergency ward of Postgraduate Institute of Medical Education and Research, Chandigarh, India with symptoms suggestive of liver abscess. Real time PCR was done to detect cf DNA in serum and urine by targeting 99-bp unit of small subunit rRNA of Entamoeba histolytica and conventional PCR for pus. Results A total 113 samples (serum and urine) and 100 pus samples were analysed. A total of 62 ALA patients were confirmed; with maximum 57 patients detected by qPCR for cfDNA in the serum, 55 patients by PCR on pus aspirate and 50 ALA patients by qPCR for cfDNA in urine sample. Therefore, the sensitivity of qPCR for detection of cf DNA in serum was 91.94% and for urine was 80.65%. Conclusion A total of 11.2% of ALA patients were diagnosed only through detection of E. histolytica cf DNA in their serum and urine. Detection of cfDNA from serum, urine of ALA has a potential role in future especially for developing countries as it is a rapid, sensitive and patient friendly diagnostic approach.

Real-time loop-mediated isothermal amplification (real-time LAMP) assay for rapid diagnosis of amoebic liver abscess.

Among the parasitic diseases, amoebic liver abscess (ALA) ranks second to malaria in terms of mortality. Due to the poor sensitivity of conventional diagnostic methods, there is a need for the development of effective and rapid diagnostic methods for ALA. Thus, the purpose of this work was to develop a real-time loop-mediated isothermal amplification (RT-LAMP) assay specific to Entamoeba histolytica. Further, we compared the performance of real-time LAMP with conventional and real-time PCR (RT-PCR) targeting 18S small subunit ribosomal RNA (18S SSU rRNA) gene of E. histolytica in patients with ALA. A total of 126 liver samples were obtained for the study. Of these, 96 aspirated pus samples were obtained from patients suffering from an ALA (serology confirmed, anti-amoebic immunoglobulin IgG positive), 19 aspirated pus samples from patients with pyogenic liver abscess (PLA, 16S RNA gene positive) and 11 autopsy liver tissues. The results showed that the DNA of E. histolytica was detected in 81 samples by conventional PCR, 93 by RT-PCR and 95 by RT-LAMP. The analytical sensitivity of the RT-LAMP assay was much higher than the other two techniques. RT-LAMP assay was able to amplify up to one copy of the targeted gene of E. histolytica while conventional PCR and RT-PCR could amplify up to 103 and 102 copies of the targeted gene of E. histolytica, respectively. In conclusion, RT-LAMP proved to be a sensitive, specific and rapid test which can be utilised as an effective tool for the diagnosis of ALA.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ ВНЕКИШЕЧНОГО АМЕБИАЗА С РАЗВИТИЕМ АБСЦЕССА ПРАВОЙ ДОЛИ ПЕЧЕНИ

Background. Due to the polymorphism, low prevalence in RB and in turn the difficulty of diagnosis, the treatment of extraintestinal amoebiasis is an important issue of surgery. Objective. To demonstrate the results of surgical treatment of a patient with amebic liver abscess. Material and methods. The article presents its own clinical observation of the surgical treatment of amebic liver abscess. The patient underwent drainage of the right liver lobe abscess under the laparoscopic control according to the method developed in the clinic. Results. The patient was discharged in satisfactory condition for further out-patient follow-up by the surgeon and infectious disease doctor at the place of residence. There were no repeated appeals and admissions. Conclusions. Clinical observation indicates the need for combined treatment of amoebic liver abscesses using external drainage in combination with conservative therapy, including the use of broad-spectrum antibiotics and metronidazole.

Involvement of NOX2-derived ROS in human hepatoma HepG2 cell death induced by Entamoeba histolytica.

Entamoeba histolytica is an enteric tissue-invasive protozoan parasite causing amoebic colitis and liver abscesses in humans. Amoebic contact with host cells activates intracellular signaling pathways that lead to host cell death via generation of caspase-3, calpain, Ca2+ elevation, and reactive oxygen species (ROS). We previously reported that various NADPH oxidases (NOXs) are responsible for ROS-dependent death of various host cells induced by amoeba. In the present study, we investigated the specific NOX isoform involved in ROS-dependent death of hepatocytes induced by amoebas. Co-incubation of hepatoma HepG2 cells with live amoebic trophozoites resulted in remarkably increased DNA fragmentation compared to cells incubated with medium alone. HepG2 cells that adhered to amoebic trophozoites showed strong dichlorodihydrofluorescein diacetate (DCF-DA) fluorescence, suggesting intracellular ROS accumulation within host cells stimulated by amoebic trophozoites. Pretreatment of HepG2 cells with the general NOX inhibitor DPI or NOX2-specific inhibitor GSK 2795039 reduced Entamoeba-induced ROS generation. Similarly, Entamoeba-induced LDH release from HepG2 cells was effectively inhibited by pretreatment with DPI or GSK 2795039. In NOX2-silenced HepG2 cells, Entamoeba-induced LDH release was also significantly inhibited compared with controls. Taken together, the results support an important role of NOX2-derived ROS in hepatocyte death induced by E. histolytica.

Preoperative Transcatheter Arterial Embolization for Spontaneous Rupture of Huge Amebic Liver Abscess with Massive Intraperitoneal Hemorrhage

An 18-year-old male developed a huge liver abscess with severe anemia over the course of 2 weeks. Abdominal contrast enhanced computed tomography showed ruptured huge liver abscess in the right liver lobe with signs of active hemorrhage (contrast extravasation). Serology examination confirmed amoeba as the suspected pathogen of cause. Angiography was performed followed by transcatheter arterial embolization to localize and control the hemorrhage. Embolization using a combination of polyvinyl alcohol and gelfoam successfully controlled the active hemorrhage. Exploratory laparotomy was performed to evacuate and debride the huge abscess. Metronidazole was given and showed good results. Huge liver abscess size is a predictor of conservative management failure and requires a gradual step-up intervention. The purpose of this paper is to explain the importance of imaging in detecting liver abscess and active hemorrhage along with the role of interventional radiology in this case.

S1591 Venous Thrombosis and Segmental Ischemia in Amebic Liver Abscess: Computed Tomographic Demonstration and its Implications

S1591 Venous Thrombosis and Segmental Ischemia in Amebic Liver Abscess: Computed Tomographic Demonstration and its Implications

Amoebic liver abscess: description of the clinical case

Amoebic liver abscess: description of the clinical case

Giant cells: multiple cells unite to survive.

Multinucleated Giant Cells (MGCs) are specialized cells that develop from the fusion of multiple cells, and their presence is commonly observed in human cells during various infections. However, MGC formation is not restricted to infections alone but can also occur through different mechanisms, such as endoreplication and abortive cell cycle. These processes lead to the formation of polyploid cells, eventually resulting in the formation of MGCs. In Entamoeba, a protozoan parasite that causes amoebic dysentery and liver abscesses in humans, the formation of MGCs is a unique phenomenon and not been reported in any other protozoa. This organism is exposed to various hostile environmental conditions, including changes in temperature, pH, and nutrient availability, which can lead to stress and damage to its cells. The formation of MGCs in Entamoeba is thought to be a survival strategy to cope with these adverse conditions. This organism forms MGCs through cell aggregation and fusion in response to osmotic and heat stress. The MGCs in Entamoeba are thought to have increased resistance to various stresses and can survive longer than normal cells under adverse conditions. This increased survival could be due to the presence of multiple nuclei, which could provide redundancy in case of DNA damage or mutations. Additionally, MGCs may play a role in the virulence of Entamoeba as they are found in the inflammatory foci of amoebic liver abscesses and other infections caused by Entamoeba. The presence of MGCs in these infections suggests that they may contribute to the pathogenesis of the disease. Overall, this article offers valuable insights into the intriguing phenomenon of MGC formation in Entamoeba. By unraveling the mechanisms behind this process and examining its implications, researchers can gain a deeper understanding of the complex biology of Entamoeba and potentially identify new targets for therapeutic interventions. The study of MGCs in Entamoeba serves as a gateway to exploring the broader field of cell fusion in various organisms, providing a foundation for future investigations into related cellular processes and their significance in health and disease.

Apocynin, an NADPH Oxidase Enzyme Inhibitor, Prevents Amebic Liver Abscess in Hamster.

Amebiasis is an intestinal infection caused by Entamoeba histolytica. Amebic liver abscess (ALA) is the most common extraintestinal complication of amebiasis. In animal models of ALA, neutrophils have been shown to be the first cells to come into contact with Entamoeba histolytica during the initial phase of ALA. One of the multiple mechanisms by which neutrophils exhibit amebicidal activity is through reactive oxygen species (ROS) and the enzyme NADPH oxidase (NOX2), which generates and transports electrons to subsequently reduce molecular oxygen into superoxide anion. Previous reports have shown that ROS release in the susceptible animal species (hamster) is mainly stimulated by the pathogen, in turn provoking such an exacerbated inflammatory reaction that it is unable to be controlled and results in the death of the animal model. Apocynin is a natural inhibitor of NADPH oxidase. No information is available on the role of NOX in the evolution of ALA in the hamster, a susceptible model. Our study showed that administration of a selective NADPH oxidase 2 (NOX2) enzyme inhibitor significantly decreases the percentage of ALA, the size of inflammatory foci, the number of neutrophils, and NOX activity indicated by the reduction in superoxide anion (O2-) production. Moreover, in vitro, the apocynin damages amoebae. Our results showed that apocynin administration induces a decrease in the activity of NOX that could favor a decrease in ALA progression.

Pleural Amebiasis without Hepar Involvement

Background: Pleuropulmonary amebiasis is the most common complication of amoebic liver abscess, occurring in 15% of patients with amoebic liver disease and in 1% of patients with amoebic dysentery. Most commonly occurs by direct extension of a right superior lobe hepatic abscess through the diaphragm to the right lower lobe of the lung with a mortality rate of 5-16%. Primary pleural amebiasis without liver involvement is rare.Case Presentation: Reported an 18-year-old male patient with pleural amebiasis from the results of parasitological examination of pleural fluid found Entamoeba histolytica. History, physical examination and support showed normal liver function. The patient has a history of poor sanitation with a dissertation of unhygienic habits. Patients without liver problems remain at risk for amoebiasis pleuraConclusion: Pleural amebiasis without liver involvement was a rare case. Further investigation was needed in patients with pleural amoebiasis to other organs, such as the liver and digestive tract. Diagnose pleural amebiasis should be the main focus in determining the etiology. Entamoeba histolytica may be involved in pleural inflammation and cause effusion.

A Man Presented with Abdominal Pain and Jaundice

<p>腹痛和黃疸於臨床常被臆斷為膽道疾病。本個案因腹痛、黃疸為表現，初期以膽道感染治療， 但因腹痛加劇、血壓下降，緊急安排腹部電腦斷層，發現左葉肝膿瘍已破裂，經皮穿肝引流治療，膿液培養出克雷白氏肺炎桿菌感染，經抽血檢測阿米巴血液凝集試驗發現阿米巴感染，投以標準用藥後病情獲得控制，預後良好。此個案免疫功能正常，但同時罹患阿米巴肝膿瘍合併細菌性肝膿瘍的感染，且發生在肝臟左葉，是極為少見的案例。臨床上個案若以腹痛、黃疸表現，但為免疫功能正常，從事高風險職業、接觸土壤或水源汙染者，應將阿米巴肝膿瘍列入鑑別診斷， 儘快釐清病因，迅速診斷，以免延誤治療先機。</p> <p> </p><p>Abdominal pain and jaundice are often clinically presumed to be symptoms of biliary tract dis­ease. This case who suffered from abdominal pain and jaundice was initially treated as biliary tract infection. However, due to the exacerbation of abdominal pain and the drop in blood pressure, the computed tomography was urgently arranged, and a rupture of abscess on left lobe was found. Per­cutaneous transhepatic drainage of abscess was performed and Klebsiella pneumoniae was cultured. Furthermore, the Amoebic hemagglutination test was positive from the blood. After standard drug treatment, the condition was controlled with good prognosis. However, in immunocompetent patients, the simultaneous occurrence of amebic and bacterial liver abscesses in the left lobe of the liver is very rare. Clinically, an immunocompetent patient presents with abdominal pain and jaundice, and those who have high-risk occupations and are exposed to soil or water pollution, amebic liver abscess should be included in the differential diagnosis. Identifying the causes as soon as possible could lead to early diagnose and to avoid the delays in treatment.</p> <p> </p>

Creep in nitroimidazole inhibitory concentration among the Entamoeba histolytica isolates causing amoebic liver abscess and screening of andrographolide as a repurposing drug

Infections by Entamoeba histolytica (E. histolytica) lead to considerable morbidity and mortality worldwide and treatment is reliant on a single class of drugs, nitroimidazoles. Treatment failures and intermittent reports of relapse from different parts of world indicate towards development of clinical drug resistance. In the present study, susceptibility testing of clinical isolates of E. histolytica was carried against metronidazole and tinidazole. Additionally, anti-amoebic property of active compounds of Andrographis paniculata was also evaluated. Prevalence of metronidazole resistance gene (nim) in patients attending hospital was also done to get comprehensive insight of present situation of drug resistance in E. histolytica. Mean inhibitory concentration 50 (IC50) value of E. histolytica isolates against metronidazole and tinidazole was 20.01 and 16.1 µM respectively. Andrographolide showed minimum mean IC50 value (3.06 µM). Significant percentage inhibition of E. histolytica isolates by andrographolide was seen as compared to metronidazole (p = 0.0495). None of E. histolytica isolates showed presence of nim gene. However, in stool samples from hospital attending population, prevalence of nimE gene was found to be 76.6% (69/90) and 62.2% (56/90) in diarrheal and non-diarrheal samples respectively. Inhibitory concentration of commonly used nitroimidazoles against clinical isolates of E. histolytica are on rise. Percentage inhibition of E. histolytica isolates by andrographolide was significantly higher than control drug metronidazole.

Gigantic Liver Abscess in Pregnancy : A Rare Case

Liver abscess (LA) is defined as a suppurated cavity caused by invasion and multiplication of microorganisms within liver parenchyma. Incidence of LA is rare with 20/100,000 admissions. Etiology of LA can be bacterial, parasitic, mixed or more rarely fungal. Amoebic liver abscess (ALA) is one of the most sequelae invasive amoebiasis with 44.1% LA in patients were caused by ALA.. Early treatment initiation is important to avoid the potential risks of preterm delivery, fetal infection, perinatal mortality, multi-organ dysfunction, sepsis, septic shock, and even maternal death. Methods tis research was case report : A 27 year old patient diagnosed with G1P0A0L0 16-17 weeks of pregnancy with LA, previously the patient went to Emergency room with complaint of upper right abdominal pain since a week and getting worsed since 1 day. The patient also complaint fever and swelling at the right abdomen. From physical examination found swelling and tenderness in the right abdomen, palpable flat surface mass and dim percussion. From an ultrasound examination is a single intrauterine live fetus, gravid 16-17 weeks according to biometry, a hypoechoic mass appeared measure 11.6 x 9.6 cm, suspected liver abscess. Then she underwent laparoscopy abscess drainage with digestive surgery collaboration, from hystopathology the result was chronic inflamation acute exaserbation might from liver abscess. Liver abscess (LA) during pregnancy is an extremely rare condition. Pregnancy has been described as a risk factor for LA because of immunological changes. Imaging modalities should be chosen with caution in the pregnant patient

Profile of Amoebic vs Pyogenic Liver Abscess and Comparison of Demographical, Clinical, and Laboratory Profiles of these Patients From a Tertiary Care Center in Northern India

Amoebic liver abscess (ALA) and pyogenic liver abscesses (PLA) are the most common causes of liver abscess in developing and developed countries, respectively. Although incidence of liver abscess is low, but mortality is high amongst the patients due to delayed diagnosis. The study was done to find out the prevalence of amoebic and PLA among patients of liver abscess. The clinical, personal, and demographical details were also evaluated to find out the risk factor(s) associated with ALA and PLA, respectively. A retrospective study was conducted to find the prevalence of amoebic and PLA. Clinical, demographic, personal details were evaluated from hospital records. Laboratory parameters such as total leucocyte count, platelets, bilirubin, ESR (Erythrocyte Sedimentation Rate), hemoglobin, glycosylated hemoglobin (HbA1c), alkaline phosphate (ALP), Aspartate aminotransferase (SGOT/AST), Alanine aminotransferase (SGPT/ALT), serum albumin, bilirubin levels, and procalcitonin were recorded. The Ultrasonography (USG) findings regarding the size, location, volume, and number of abscesses were also analyzed. Total of 107 patients of liver abscess were evaluated, and 61.6% of patients were of amoebic etiology, and 25.3% were of pyogenic etiology. Males of 20-60 years of age were predominantly affected with right upper quadrant pain and fever as the most common presentations. ALA patients were found to have solitary abscess in the right lobe involving 6th and 7th segments, with decreased hemoglobin, hyperbilirubinemia, elevated ALP and SGOT, with normal SGPT, and addiction to alcohol. PLA patients had increased HbA1c, increased PCT values, low serum albumin levels, and low platelet-to-white blood cellvalues. The most common bacteria causing PLA was Escherichia coli (n= 8) followed by Enterobacter cloacae (n= 5). Mortality was seen in 6 patients. Liver abscess is found to have relatively high mortality and morbidity. Therefore, early diagnosis is the only method to prevent mortality and morbidity in these patients. Since the presentation is very nonspecific, evaluation of certain risk factors and laboratory parameters can aid in the diagnosis.