Impaired Liver Function Tests Research Articles

Short-Term Side Effects of Low Dose Valproate Monotherapy in Epileptic Children: A Prospective Study.

Considering the common use of valproate among children, we investigated the short-term side-effects of low dose valproate monotherapy in epileptic children. In this prospective study, 209 epileptic children (48.3% male, mean age: 7.02 ± 3.13 yr) on low therapeutic dose of valproate monotherapy (20-30 mg/kg/d) were enrolled during 2014-2015 in Isfahan Pediatric Neurology Clinic, Isfahan University of Medical Sciences, Isfahan, Iran and side-effects were evaluated through frequent clinical visits and laboratory tests during 6 months of valproate therapy. Weight gain was reported in 53.1% of patients. Decreased appetite was seen in 11% of patients, more frequent in younger cases (P=0.006). Abdominal pain, nausea/vomiting, diarrhea, and constipation were reported in 16.3%, 2.4%, 1.4%, and 1% of patients, respectively. Headache, tremor, dizziness, abnormal color vision, myoclonus, and bruxism were seen in 5.7%, 1.4%, 1%, 1%, 1%, and 0.5% of patients, respectively. Enuresis, hair loss, and skin rash were reported in 8.1%, 6.7%, and 0.5% of patients, respectively. Thrombocytopenia, impaired liver function tests, and leukopenia occurred in 1%, 1%, and 0.5% of patients, respectively. Low dose valproate monotherapy may cause numerous side-effects, mostly not life-threatening and requiring no action. Besides more reported complications, we observed decreased appetite (among younger patients), enuresis, and abnormal color vision which are onlybriefly discussed in the literature and need to be addressed more.

A coinfection of severe leptospirosis and scrub typhus in Indian Himalayas

Scrub typhus and leptospirosis are zoonosis and systemic febrile illnesses with diverse, nonspecific clinical manifestations, and shared risk factors for coinfection. Diagnosis of the coinfection is dependent on laboratory serological tests, which are under used. A coinfection from Uttarakhand Himalayan region is not yet reported. A 25-year-old man from altitude of 2126 feet above sea level presented with fever, myalgia, jaundice, oliguria, mental confusion, and tender hepatomegaly. Investigations revealed leukocytosis, thrombocytopenia, impaired liver function tests, renal dysfunction with neurological involvement. Leptospira immunoglobulin IgM enzyme linked immunosorbent assay (ELISA) and scrub typhus immunochromatography test were positive. This coinfection is first to be documented in this holy Indian Himalayas. Clinical suspicion, early laboratory diagnosis, and early treatment could prevent complications and fatal outcomes. Coinfection of this type may be considered when there is persistence of fever and a treatment response to doxycycline.

Mycoplasma pneumoniae in pediatric patients: Do macrolide-resistance and/or delayed treatment matter?

Mycoplasma pneumoniae is a common pathogen for pneumonia in children, especially in the post-pneumococcal conjugate vaccination era. Though self-limited disease was found in the majority of the patients, severe diseases occurred occasionally. The emergence of macrolide resistance was reported worldwide. It is important to delineate whether macrolide resistance or delayed treatment affects outcome. We retrospectively collected pediatric patients with M. pneumoniae infection confirmed by positive PCR in a tertiary medical center in Taiwan from 2010 to 2017. Patients' clinical characteristics, bacterial load, macrolide resistance and treatment outcome were analyzed. Among 471 children with positive M.pneumoniae PCR, 95% were diagnosed with pneumonia. Seventeen percent of patients had extrapulmonary complications, and 1.5% had respiratory failure. Delayed treatment was associated with prolonged fever after appropriate treatment, fulminant disease, and extrapulmonary manifestations (p<0.05). The mean rate of macrolide resistance was 24% and macrolide resistance was related to longer febrile duration, longer hospital stay, lung consolidation and impaired liver function tests (P<0.05). Macrolide resistance was fairly common and might lead to delayed appropriate antibiotic treatment. Delayed appropriate antimicrobial treatment, no matter macrolide resistance or not, was associated with more severe and/or prolonged diseases. Early diagnosis of M.pneumoniae as well as the awareness of macrolide resistance make early effective antibiotic treatment possible and may improve clinical outcomes.

Biliary complications after liver transplantation: Assessment with MR cholangiopancreatography and MR imaging at 3T device

PurposeOur study was aimed to assess the diagnostic value of MR cholangiopancreatography (MRCP) and MR imaging at 3 T device when evaluating biliary adverse events after liver transplantation. Materials and methodsA series of 384 MR examinations in 232 liver transplant subjects with suspected biliary complications (impaired liver function tests and/or biliary abnormalities on ultrasound) were performed at 3 T device (GE-DISCOVERY MR750; GE Healthcare). After the acquisition of axial 3D dual-echo T1-weighted images and T2-weighted sequences (propeller and SS-FSE), MRCP was performed through coronal thin-slab 3D-FRFSE and coronal oblique thick-slab SSFSE T2w sequences. DW-MRI of the liver was performed using an axial spin-echo echo-planar sequence with multiple b values (150, 500, 1000, 1500 s/mm2) in all diffusion directions. Contrast-enhanced MRCP was performed in 25/232 patients. All MR images were blindly evaluated by two experienced abdominal radiologists in consensus to determine the presence of biliary complications, whose final diagnosis was based on direct cholangiography, surgery and integrating clinical follow-up with ultrasound and/or MRI findings. ResultsIn 113 patients no biliary abnormality was observed. The remaining 119 subjects were affected by one or more of the following complications: non-anastomotic strictures including typical ischemic-type biliary lesions (n = 67), anastomotic strictures (n = 34), ampullary dysfunction (n = 4), anastomotic leakage (n = 4), stones, sludge and casts (n = 65), vanishing bile duct (n = 1). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of the reviewers for the detection of all types of biliary complications were 99%, 96%, 95%, 99% and 97%, respectively. ConclusionMR cholangiopancreatography and MR imaging at 3 T device are extremely reliable for detecting biliary complications after liver transplantation.

Harmonic Scalpel-Assisted Laparoscopic Cholecystectomy vs. Conventional Laparoscopic Cholecystectomy - A Non-randomized Control Trial.

IntroductionLaparoscopic cholecystectomy (LC) is the most commonly done, minimally invasive surgical procedure. Routinely used electrocautery produces more smoke, which masks the operating field, thereby prolongs the surgery and posing an increased risk of gallbladder (GB) perforation. The titanium clips used for clipping the cystic artery and cystic duct have a risk of slippage, which may lead to bleeding, and an increased risk for bile leakage. In addition, it may act as a nidus for stone formation. Advanced energy sources, such as the harmonic scalpel, though expensive, may provide the advantage of shorter operating time by reducing smoke, bloodless dissection in the GB bed, lower risk of bleeding from the cystic artery due to secure vessel sealing, and avoiding the use of a larger number of titanium clips. However, evidence to substantiate this advantage is limited.AimTo compare the operating time and perioperative complications between conventional laparoscopic cholecystectomy (CLC) and harmonic scalpel assisted laparoscopic cholecystectomy (HLC).MethodologyAll consecutive patients who underwent elective LC were included. Patients with acute infection, impaired liver function tests, concomitant common bile duct calculi, chronic liver disease/cirrhosis, suspected GB carcinoma, and pregnant women were excluded from the study. Patients were allocated into two groups. In the CLC group, both the cystic duct and the cystic artery were divided after conventional titanium clip application and electrocautery was used for thermal energy. In the HLC group, the cystic duct was clipped with a titanium clip and the rest of the procedure was carried out using Harmonic Ace (Ethicon, New Jersey, United States) and Harmonic Hook (Ethicon, New Jersey, United States). Outcome parameters analyzed were operating time in minutes, post-operative pain using visual analogue scale (VAS) scoring, frequency and route of analgesic requirement after 24 hours, and intraoperative complications, including bleeding, bile duct injury, GB perforation, and surgical site infection (SSI) in the postoperative period, per the Centers for Disease Control (CDC) criteria.ResultsBoth the groups were comparable with respect to age, gender, body mass index (BMI), and the presence of comorbidity and an indication of cholecystectomy. The duration of surgery did not significantly differ between the groups (67.3 vs. 64.3 mins; p = 0.30). Other parameters, such as analgesic required on postoperative Day 1 (3.2 vs. 3; p = 0.67), VAS scores on Day 0 (4.55 vs. 4.65; p = 0.59), VAS scores on Day 1 (2.3 vs. 2.2; p = 0.84), superficial SSI (15% vs. 10%; p = 0.63), intraoperative GB perforation (30% vs. 20%; p = 0.71), and intraperitoneal drain (30% vs. 20%; p = 0.71) did not significantly differ between the groups.ConclusionHLC has no significant advantage over CLC with respect to operating time, postoperative pain, and perioperative complications.

Clinical Significance of Impaired Liver Function Tests in Decompensated Heart Failure

Background: Therapeutic progress in chronic heart failure has not been reflected in decompensated patients, compelling the need for new therapeutic and prognostic tools. Although liver function tests are part of routine admission studies, their clinical significance is not clearly established. Objective: The aim of this study was to evaluate the prognostic relevance of liver function tests in decompensated heart failure. Methods: The study analyzed the prevalence and in-hospital mortality association of elevated (at least twice the normal value) total bilirubin (TB), alkaline phosphatase (APh) and alanine aminotransferase (ALT) or aspartate aminotransferase (AST) in 700 consecutive patients admitted into two coronary care units due to decompensated heart failure, with liver function tests at admission, and no previous liver disease. Results: In 20.8% of cases, patients presented some abnormal liver function test: 6%, increased TB, 12.6% increased ALT or AST and 12.6% increased APh. In the univariate analysis [(OR (95% CI)], any abnormal liver function test [2.34 (1.18-4.65)], TB [4.05 (1.66-9.83)], ALT/AST [3.56 (1.72-7.34)] but not APh was associated with higher in-hospital mortality. In the multivariate model, cardiogenic shock [9.48 (2.31-38.78)], TB [3.61 (1.29-10.04)], AST/ALT [2.83 (1.28-6.25)], renal failure at admission [3.55 (1.48-8.49)] and history of chronic obstructive pulmonary disease [2.66 (1.21-5.87)] were independently associated with mortality. Conclusions: Accessible tests such as liver function assessment provide additional prognostic information at admission. In an unselected patient population, abnormal liver function may probably express increased vulnerability rather than hemodynamic impairment.

Case of impaired liver function test due to intake of hormones for long time with DUB cured by homeopathy

Case of impaired liver function test due to intake of hormones for long time with DUB cured by homeopathy

Thymoquinone restores liver fibrosis and improves oxidative stress status in a lipopolysaccharide-induced inflammation model in rats.

Liver fibrosis is the primary sign of chronic liver injury induced by various causes. Thymoquinone (TQ) is the major ingredient of Nigella sativa with several beneficial effects on the body. In the present study, we aimed to investigate the effect of TQ on liver fibrosis in a lipopolysaccharide (LPS)-induced inflammation in male rats. Fifty male Wistar rats were randomly divided into five groups (n=10 in each group) as follow: (1) control; (2) LPS (1 mg/kg/day; i.p); (3) LPS+TQ 2 mg/kg/day (i.p) (LPs+TQ2); (4) LPS+TQ 5 mg/kg/day (LPS+TQ5); (5) LPS+ TQ 10 mg/kg/day (LPS+ TQ10). After three weeks, blood samples were taken for evaluation of liver function tests. Then, the livers were harvested for histological evaluation of fibrosis and collagen content and measurement of oxidative stress markers including malondialdehyde (MDA), total thiol groups, superoxide dismutase (SOD) and catalase activity in tissue homogenates. LPS group showed higher levels of fibrosis and collagen content stained by Masson's trichrome in liver tissue with impaired liver function test and increased oxidative stress markers (p<0.05). Treatment by TQ restored liver fibrosis, improved liver function tests and increased the levels of anti-oxidative enzymes (SOD and catalase), while reduced MDA concentration (p<0.05). Treatment by TQ restores inflammation-induced liver fibrosis possibly through affecting oxidative stress status. It seems that administration of TQ can be considered as a part of liver fibrosis management.

Approach to Impaired Liver Function Tests

Approach to Impaired Liver Function Tests

Approach to Impaired Liver Function Tests

Approach to Impaired Liver Function Tests

Parenteral fish oil and liver function tests in hospitalized adult patients receiving parenteral nutrition: A propensity score-matched analysis

Intravenous fat emulsions are associated with liver disease and there is some evidence that the administration of intravenous fish oil (FO) may be useful in reversing it. The aim of our study was to assess whether there are differences in the changes of liver function tests (LFTs) in hospitalized adult patients with parenteral nutrition (PN) with FO and vegetal lipids vs patients without FO. The secondary aim was to study the relationship between impaired LFT and FO. This was a 4-year, propensity score-matched analysis including patients aged ≥18 years treated with PN for ≥10 days. The exclusion criteria were previous liver disease, biliary disorders or pancreatic cancer, and altered initial LFT values. Patients were classified into 2 groups: FO cohort (patients who received FO - in addition to vegetal oil - after the first week of PN) and the vegetal oil cohort (patients who received only vegetal oil). A propensity score matched cohort design was developed. Univariate analyses were used to study the changes in LFTs. To evaluate whether LFT alterations vary with FO administration, four stepwise multiple linear regression models were conducted. 52 patients were included, 52% men, median 66 (55-75) years and 69kg (61.7-78.8), with 18.5 (14-31.8) days of PN treatment. Maximum FO supplementation was 23%. During the first week with PN (none of the groups receiving FO), gammaglutamyl transferase (GGT), alkaline phosphatase (AP) and total bilirubin (BIL) increased significantly. Comparing LFT values at seven days of PN with at the end of PN treatment, the univariate analysis showed a better response for the FO group. The group without FO showed a significant increase for GGT and AP. In multivariate models, the percentage of FO administered was associated with a decrease in GGT, B=-0.33 [CI 95%=-0.54/-0.12], in AP, B=-0.12 [CI 95%=-0.20/-0.03] and ALT, B=-0.12 [CI 95%=-0.21/-0.024]. Lipid composition plays a significant role in LFT alteration associated with PN, and FO intravenous lipid emulsions (ILEs) minimize disturbance of LFTs in hospitalized adult patients.

Autoimmune Hepatitis as an Initial Presentation of SLE

: An 11-year-old female patient with autoimmune hepatitis (AIH) was referred to our rheumatology clinic due to her current musculoskeletal manifestations. The patient had been diagnosed with AIH 3 months previously, based on jaundice and impaired liver function tests, and she had been treated with low-dose prednisolone and azathioprine. She presented with malaise, arthritis, a malar rash on the face, and oral ulcers. Laboratory tests revealed a positive ANA/anti-dsDNA test. Liver biopsy showed chronic hepatitis with severe inflammatory activity, in favor of a diagnosis of definite AIH. She fulfilled the international criteria for both SLE and AIH. The clinical symptoms and laboratory findings of SLE improved with ongoing treatment with corticosteroids and azathioprine, accompanied with hydroxychloroquine sulfate. The present case indicates that AIH can be the first manifestation of SLE in children.

Heparin-Induced Thrombocytopenia Association with Impaired Liver Function Tests

Heparin-Induced Thrombocytopenia Association with Impaired Liver Function Tests

PP.22.15

Objective: Recently the impact of acute decompensated heart failure (ADHF) on hepatic function has been described as cardio-hepatic syndrome. It is assumed that cytolysis is mainly associated with systemic hypoperfusion, whereas cholestasis - with volume overload. Systemic congestion is the known main driver for morbidity, mortality and hospital readmission of patients with ADHF. The aim of this study was to determine possible association of impaired liver function tests (LFT) with hydration status in patients with ADHF. Design and method: In 200 patients with ADHF (84 male, 72.9 ± 10.7 years(M ± SD), arterial hypertension 79%, myocardial infarction 43%, atrial fibrillation (AF) 62%, diabetes mellitus 36.5%, chronic kidney disease (CKD) 38%, anaemia 23.5%, chronic obstructive lung disease 23.5%, ejection fraction(EF) 45 ± 12%, EF < 35% 25%, chronic hepatic diseases 9.5%) alanine transaminase(ALT), aspartate transaminase(AST), total bilirubin, alkaline phosphatase (AP), gamma-glutamyl transpeptidase(GGT) were measured and hydration status by bioimpedance vector analysis (BIVA) was assessed using resistance(R) and reactance(Xc), standardized by height(h). LFTs were considered abnormal when levels exceeded local upper normal levels. Mann-Whitney and Spearman test were performed. P < 0.05 was considered statistically significant. Results: Increase of ALT and/or AST occurred in 29 (14.5%) patients (alone ALT/ alone AST/ both TA – in 42.3, 19.2, 38.5% respectively), increase of bilirubin,AP and GGT - in 68(34%), 14(7%), 20(10%) patients respectively. Patients with versus without transaminases increase had higher rate of signs of congestion: echo-hydropericardium (33 vs 12%, p < 0.01), radiological signs of hydrothorax (72 vs 32%, p < 0.001), jugular venous distension (55 vs 21%, p < 0.001). The patients with versus without increase of bilirubin demonstrated higher volume overload: lower levels of both R/h and Xc/h (218 ± 44 vs 238 ± 54 Om/m, p < 0.01 and 16 ± 7 vs 19 ± 8 Om/m, p < 0.01). Negative correlations between serum bilirubin and BIVA parameters of hyperhydration were revealed (r = −0.38 for R/h and r = −0.29 for Rx/h, p < 0.05). Conclusions: Impaired LFT were common in patients with ADHF and were associated with signs of congestion (hydropericardium, hydrothorax, jugular venous distension). Increase of bilirubin was associated with higher volume overload assessed by BIVA. The results of the study suggest that congestion may be important in the development of cardiohepatic syndrome in patients with ADHF.

Paraclinical Evolutions Regarding Liver and Renal Abnormalities of Kawasaki Disease in the Southeast of Iran

Background: Kawasaki disease (KD) is a vasculitis affecting multi-organ systems including liver and kidneys. KD is diagnosed by some clinical criteria including sterile pyuria, microscopic hematuria, proteinuria due to renal involvement, liver abnormalities manifesting as abnormal liver function tests, gallbladder hydrops, and hypoalbuminemia. Objectives: The aim of the study was to determine the frequency of liver and renal abnormalities in patients with KD, hospitalized in Ali-Ebne-Abitaleb Hospital of Zahedan during 2006 - 2013. Materials and Methods: Paraclinical findings including serum and urine tests as well as gallbladder ultrasonography of 47 patients with KD hospitalized in Ali-Ebne-Abitaleb Hospital of Zahedan during 2006 - 2013 were reviewed retrospectively. Results: Liver abnormalities were found in 22 (46.8%) cases and impaired liver function tests were more common than other liver abnormalities in this cross-sectional study. The incidence of abnormal liver function tests in this study was about 42%. Gallbladder hydrops were found in 6 (12.7%) patients and 18 (38.3%) had renal involvement. Sterile pyuria was the most common urine abnormality with incidence of 36.2%. Microscopic hematuria and proteinuria were rarely found; in addition, serum urea nitrogen and creatinine had normal levels in all patients. Conclusions: The possibility of KD should be considered in any infants or children with abnormal results in liver or renal function tests. Paraclinical findings of liver and renal involvements of all patients were partly similar to the previous studies.

A9.1 Macrophage activation syndrome after mycoplasma pneumoniae infection

Introduction Macrophage activation syndrome is a rare and potentially life threatening condition, triggered by various events like bacterial and viral illness and sometimes it can be a complication of childhood...

Risks of herbalism: a case report of Mexican poppy (Argemone mexicana L) induced liver toxicity

The increasing consumption of alternative medicines has lead to a greater awareness about the deleterious effects and interactions that these products can induce. Consequently, medical literature reports liver toxicity from Aloe, Camellia sinensis (green tea), Rhammus purshianus, Aesculus hippocastanum (buckeye) and Valeriana officinalis (valerian), among others. This article reports a female patient who twice consumed Mexican poppy (Argemone mexicana L) with a one-year interval between ingestions. Both times she developed diarrhea, jaundice and general malaise with impaired liver function tests. Other causes of liver disease were ruled out. Questionnaires were used to assess the possibility of drug-induced liver damage. Clinical information was collected from the patient’s medical record and the literature on the subject was reviewed. We conclude that, at least in this case, the most likely cause of liver toxicity was Argemone mexicana L consumption.

Travel‐Related Leptospirosis: A Series of 15 Imported Cases

Leptospirosis belongs to the spectrum of travel-related infections. We retrospectively studied all the consecutive cases of travel-related leptospirosis seen in our department between January 2008 and September 2011. Patients were included with a clinical picture compatible with the disease within 21 days after return, the presence of a thermoresistant antigen or IgM antibodies, Elisa ≥ 1 /400, and a positive microagglutination test (MAT) ≥ 1/100. Fifteen leptospirosis cases were evaluated. Exposure occurred in Asia (47%), Africa (20%), the Caribbean (20%), and Indian Ocean (13%). Fourteen patients were infected during water-related activities. On admission the most frequent symptoms were fever (100%), headache (80%), and digestive disorders (67%). Relevant laboratory findings included impaired liver function tests (100%), lymphocytopenia (80%), thrombocytopenia (67%), and elevated C-reactive protein (CRP) (67%). Our cases were confirmed by MAT that found antibodies against nine different serovars. Seven patients were cured with amoxicillin, four with doxycycline, two with ceftriaxone, one with ceftriaxone, doxycycline, and spiramycin, whereas one recovered spontaneously (retrospective diagnosis). Eight patients were hospitalized. All patients recovered. Our cases involved nine different serovars. They were related to travel in Asia, Africa, and the Caribbean. Bathing or other fresh-water leisure activities (canoeing, kayaking, rafting) are the most likely at-risk exposure. Any traveler with fever and at-risk exposure should be investigated for leptospirosis.

Nifurtimox therapy for Chagas disease does not cause hypersensitivity reactions in patients with such previous adverse reactions during benznidazole treatment

Currently, only two drugs are approved for treating Trypanosoma cruzi infection: benznidazole and nifurtimox. Adverse reactions are frequent with both drugs: they have chemical similarities and common metabolic pathways making cross reactions a possibility. Our objective was to describe the safety/tolerability profile of nifurtimox in patients who had previously discontinued benznidazole due to hypersensitivity reactions. We performed a prospective observational study from September 2009 to December 2011. Patients who discontinued benznidazole therapy due to hypersensitivity reactions (HR) and were later treated with nifurtimox were included. HR to benznidazole were defined as presence of a rash with or without mucosal involvement, fever or laboratory abnormalities (such as eosinophilia, leucopaenia or impaired liver function tests). The drugs were prescribed for 60 days (benznidazole) or 60–90 days (nifurtimox). The National Cancer Institute criteria (CTCAE, 2006, Version 3.0) were used for grading and reporting of adverse reactions (AR). Eighteen patients (16 females, two males, median age 35.5 years, range 15–50 years) with asymptomatic late chronic infection, were included. Median time between benznidazole interruption and start of therapy with nifurtimox was 121.5 days (IQR 72–223 days). Fifteen patients (83.3%) developed an AR to nifurtimox, gastrointestinal complaints and anorexia being the most common, and 13 patients (72%) completed the treatment schedule. Five patients interrupted therapy (27.8%) mainly because of gastrointestinal intolerance and/or nervous system toxicity. Only one patient developed skin lesions, a mild maculopapular rash not requiring specific therapy or treatment withdrawal. There was no severe AR. Nifurtimox as second line therapy in patients who discontinued benznidazole specifically due to HR appears to be safe and does not seem to be associated with a higher incidence of AR.

Severe systemic sepsis due to pyogenic liver abscess

Pyogenic liver abscess is a potentially life-threatening disease with a reported mortality of up to 30–50%. Escherichia coli and Klebsiella pneumoniae (Kp) are the most important pathogens for pyogenic liver abscess. Modern imaging techniques such as ultrasonography (USG) and computed tomography (CT) are used for diagnosis and treatment. Treatment with intravenous (iv) antibiotics and application of catheter drainage (under the guidance of imaging techniques) are the principal therapies. Surgical intervention is indicated if failure of medical treatment and rupture of abscess are noted [1, 2] Herein, we present the case of a pyogenic liver abscess due to Kp in a diabetic man in our intensive care unit (ICU). A 60-year-old man with a history of diabetes mellitus was referred to our ICU with deterioration of his general condition. He was treated for suspected urinary tract infection in another hospital for several days, but the symptoms were not resolved. On admission, he was septic with a clouding of consciousness. On examination, he had tachypnea, tachycardia, hypoxemia, fever and impaired peripheral circulation with acral cyanosis. He was hypotensive with a systolic blood pressure of 70 mmHg and responded to fluid resuscitation, but subsequently required ventilatory support for respiratory deterioration. He had acute renal impairment requiring hemodialysis, and disseminated intravascular coagulopathy (DIC), secondary to sepsis. Laboratory tests also revealed impaired liver and renal function tests, leukocytosis, high erythrocyte sedimentation rate and an elevated C reactive protein (CRP) level. Chest X-ray showed consolidation on bilateral lower zones of the lungs. Antibiotherapy was initiated with iv administration of imipenem and ciprofloxacin after blood, urine, and tracheal aspirate cultures were obtained. A bedside abdominal USG showed a thick walled cystic lesion, 7 cm in diameter, in the right lobe of the liver and it was interpreted as liver abscess. Cranial, thoracal and abdominal CTs were performed subsequently. Cranial CT was normal. Thoracal CT revealed multiple cavitating nodules in lung parenchyma, pneumonic consolidations on bilateral basal segments and bilateral minimal pleural effusions (accepted as spread of infection to the lung via septic emboli). Abdominal CT revealed an abscess (7 cm 9 5 cm 9 5 cm) in the right lobe of the liver (Fig. 1). Percutaneous drainage of the liver abscess with the guidance of abdominal USG was performed on the fourth day after hospitalization. The thick pus was drained with needle aspiration and the drainage catheter was left in situ and attached to an external drainage bag. Cultures of the liver aspirate eventually grew Kp. Kp was also found in one set of blood cultures performed on admission. Intravenous antibiotics were not changed according to antimicrobial sensitivities. Despite continued treatment with appropriate antibiotics and drainage, he worsened and died because of disseminated Kp infection and sepsis on the seventh day after hospitalization. Most pyogenic liver abscesses are secondary to infection originating in the abdomen. Cholangitis due to stones or G. Aygencel (&) Division of Critical Care Medicine, Department of Internal Medicine, Gazi University Faculty of Medicine, Besevler, 06510 Ankara, Turkey e-mail: aygencel@hotmail.com