Ml Of Purulent Material Research Articles

S2761 Recurrent Oriental Cholangiohepatitis Despite Partial Hepatic Resection

Introduction: Recurrent pyogenic cholangiohepatitis (RPC), also known as “Oriental Cholangiohepatitis”, is commonly found in people of Southeast Asian origin. RPC is characterized by recurrent cholangitis secondary to bile stasis and stone formation proximal to biliary strictures. We present a case of recurrent pyogenic cholangiohepatitis with hepatic abscess in a Vietnamese male with history of partial hepatic resection. Case Description/Methods: A 42 year old Vietnamese male with a past medical history of recurrent pyogenic cholangitis and hepatolithiasis status post hepaticojejunostomy in 2009, followed by abscess resection with culture positive Klebsiella, segment 3 resection, and biliary stenting in 2013 presented with two days of RUQ pain, fevers and jaundice. On arrival, the patient was afebrile, tachycardic and mildly hypotensive. Laboratory evaluation demonstrated alkaline phosphatase 360 IU/L, total bilirubin 14.4 mg/dL, ALT 93 IU/L, AST 113 IU/L, WBC 24,000, INR 1.3. Findings on CT scan of the abdomen included 10 cm multiloculated liver abscess in segment 4A, dilated biliary tract with small pneumobilia and dense material, and a 3.9 x 2.8 cm mass-like hyperdense region in the portal triad region visualized in arterial phase. The patient was started on broad spectrum antibiotics and underwent percutaneous abscess drainage with 350 mL of purulent material removed. MRCP the following day redemonstrated a liver abscess measuring 9.5 cm, RUQ drain in place, diffuse dilatation of the intrahepatic and extrahepatic bile ducts with multiple filling defects consistent with calculi, and a 14mm common bile duct. Cultures from the abscess grew ESBL E.coli and Provotella, and the patient was transitioned to Ertapenem with plan to continue antibiotics for four weeks. The patient was discharged home with abscess drain in place. Discussion: RPC is a recurrent syndrome of cholangitis triggered by a parasitic infection which causes biliary fibrosis leading to strictures and stone formation within intrahepatic ducts, most often on the left. Treatment includes antibiotics, stricture dilation, biliary drainage, stone removal, and liver resection. Although liver resection of the segment decreases the risk of recurrent cholangitis, abscess, and eliminates the risk of carcinoma in that segment, resection does not resolve the biliary fibrosis throughout the remaining segments leaving the patient at risk for recurrence. Liver transplant can be considered for complicated cases that do not respond to conventional therapies.Figure 1.: 10 cm multiloculated liver abscess in segment 4A.

Understanding the Head and Neck Ultrasound: From Simple to Complicated Cases: Submandibular Abscess

A 43-year-old man was referred to center of maxillofacial surgery and dentistry with a very painful and severe swelling in the left submandibular area, redness of the neck, fever for 1 week, and slight worsening of swallowing. According to history of patient`s complaints, 10 days ago in the area of the present swelling, several movable lesions in the depth of soft tissue were noted. Longitudinal gray scale ultrasound (US) (Panel B, US using linear probe; Panel C, US using convex probe) showed subcutaneous oedema (white asterisk), large collection of well-defiened hypoechoic fluid (indicated by ‘+’ and ‘×’ calipers) under the platysma muscle (arrowheads). Movement of the fluid during dynamic compression was noted. The usual artifact for fluid-contained objects, posterior acoustic enhancement, is indicated by black asterisks. No ultrasound signs of gas loculations in the soft tissue and fluid were found. This allows assuming the absence of gas-forming organisms. Also, the enlarged lymph nodes were noted at the left neck. The diagnosis of submandibular abscess due to non-odontogenic inflammation and suppurate fusion of the lymph nodes was established. The abscess was lanced, and drained using submandibular approach. 18 ml of purulent material was obtained. At the next morning after surgery, the patient felt significant improvement; 1 week follow-up the patient was clinically well.

Primary purulent bacterial pericarditis due to Streptococcus intermedius in an immunocompetent adult: a case report

BackgroundAcute purulent bacterial pericarditis is of rare occurrence in this modern antibiotic era. Primary involvement of the pericardium without evidence of underlying infection elsewhere is even rarer. It is a rapidly progressive infection with high mortality. We present an extremely rare case of acute purulent bacterial pericarditis in an immunocompetent adult patient with no underlying chronic medical conditions.Case presentationA 33-year-old previously healthy white man presented with the complaints of chest pain and dyspnea. He was diagnosed as having acute pericarditis and was discharged home on indomethacin. Over a period of 2 weeks, his symptoms worsened gradually and he was readmitted to our hospital. He was found to have large pericardial effusion with cardiac tamponade. An urgent pericardiocentesis was done with drainage of 550 ml of purulent material. Cultures grew Streptococcus intermedius confirming the diagnosis of acute purulent bacterial pericarditis. No other focus of infection was identified on imaging workup suggesting primary infection of the pericardium. His clinical course was complicated by development of constrictive pericarditis for which he underwent surgical pericardiectomy. He received a total of 7 weeks of intravenously administered antibiotics with complete clinical recovery.ConclusionsAcute purulent bacterial pericarditis, although rare, should always be kept in mind as a possible cause of pericarditis. Early recognition and prompt intervention are important for a successful outcome.

Complications in Caroli Disease

Purpose: Caroli disease is a rare inherited disorder characterized by nonobstructive, multifocal areas of saccular dilatation of intrahepatic biliary ducts. It is thought to be a genetically acquired disease, and is linked often to autosomal recessive polycystic kidney disease. It is diagnosed through imaging, and magnetic resonance cholangiopancreatography (MRCP) is emerging as the diagnostic modality of choice. A 62-year-old female with previously diagnosed Caroli disease and polycystic kidney disease presented as a hospital transfer for further evaluation of a complex liver cyst. Prior to admission, she had a complicated course with intermittent severe abdominal pain that was occurring over the past 3 weeks. Initially, when she sought treatment, she was provided an oral narcotic and sent home. The subsequent week, she developed fevers and returned to the outside hospital, was admitted, treated with unknown antibiotics for presumed colitis, and discharged after improvement. A week thereafter, she developed dyspnea on exertion, ascites, and edema of her lower extremities, causing her return to the hospital. During her second outside hospital admission, she was noted to be jaundiced and spiking intermittent fevers. Magnetic resonance imaging (MRI) was performed, which demonstrated a complex liver cyst abutting the upper pole of the right kidney, which appeared infected. Upon arrival to our facility, blood cultures were obtained, intravenous fluids were initiated, and piperacillin-tazobactam was continued. MRI showed a 6.7-cm hepatic cyst in segment VI of the liver with a fluid level, thickened walls, and edema in surrounding hepatic parenchyma. US-guided drainage of 60 mL of purulent material and fluoroscopic-guided 10 french drain was placed via the transhepatic approach. Cyst fluid revealed aerobic culture, showing no growth and anaerobic culture showing Bacteroides fragilis. The patient's abdominal pain improved, she remained afebrile, and blood cultures were negative. She was subsequently discharged with 6 weeks of levofloxacin and metronidazole, with follow-up appointments for her hepatic drain to be evaluated and with infectious disease. Morbidity and mortality from Caroli disease usually comes from complications including cholangitis, hepatolithiasis, biliary abscesses, sepsis, cirrhosis, portal hypertension, cholangiocarcinoma, and renal failure. Prognosis is determined largely by the frequency and severity of cholangitis, which can cause sepsis or death. This case illustrates the potential for complications in Caroli disease and the importance of definitive identification of any source of abdominal pain in these patients. Delay in diagnosis and treatment can lead to significant morbidity and mortality.

Pyogenic Liver Abscess Due to Diverticulitis

Purpose: AIM: Diverticulitis involving the colon can occasionally present with complications, including perforation, obstruction and abscess. This report describes a case of sigmoid diverticulitis which presented with a protracted illness related to a large hepatic abscess. CASE REPORT: A 43 yo male with a history of systemic hypertension and sleep apnea presented in 7/10 with complaints of fever, upper abdominal pain and 12 lb weight loss over the preceding 6 mos. Physical examination revealed signs of dehydration, lowgrade fever and right upper quadrant tenderness. CT scan showed a 12.3 cm x 9.9 cm heterogeneous right liver lobe mass and a 3.5 cm peri-sigmoid soft tissue mass which contained an air locule. Lab tests indicated: serum bilirubin 1.6 mg/dl (N=0.2-1.1), serum transaminase levels 3 X ULN, serum alkaline phosphatase 3X ULN and peripheral leukocyte count 16,100 (N=4,200-10,800). A serum CEA level was 0.2 (N= < 2.5 mg/ml for non-smoker). The patient was admitted to the hospital for hydration and expedited evaluation. Colonoscopy revealed moderate sigmoid diverticulosis and a short segment of mid-sigmoid luminal erythema and edema. A diagnosis of presumptive sigmoid diverticulitis with pericolonic and pyogenic liver abscess was made and broad-spectrum antibiotics (levofloxacin and metronidazole) were instituted. The patient underwent aspiration of the liver lesion under CT-guidance, which yielded ˜750 ml of purulent material. A percutaneous drain was left in the liver and antibiotics were continued. The fluid did not grow any pathogens, although the pyogenic abscess was presumed to be bacterial in etiology. It was believed that bacterial pathogens were not isolated from the abscess as the patient had been receiving antibiotics for ˜ 36 hrs prior to the CT-guided liver drainage procedure. He was discharged home on ertapenem intravenously. The patient was followed on an outpatient basis by serial CT scanning and clinical evaluation, and periodic repositioning of the drain within the liver abscess cavity occurred. The abscess progressively diminished in size and the final CT scan, performed 16 weeks after his initial presentation, revealed collapse and resolution of the liver abscess cavity. The patient then underwent uneventful elective laparoscopic sigmoid resection. The patient ultimately made a full and unremarkable recovery. CONCLUSION: This case describes a patient presenting with sigmoid diverticulitis with localized peri-sigmoid abscess, and large pyogenic liver abscess. Combined prolonged antibiotic therapy and percutaneous liver abscess drainage led to clinical and radiographic resolution of the abscess.

Overcoming the Rigors of Klebsiella pneumoniae

A 57-year-old Japanese man with non-insulin-dependent diabetes mellitus presented with 3 weeks of fevers, chills, and a 15-pound weight loss. On examination, he was afebrile (37.5 C) and hypotensive (99/60 mmHg). He was noted to have severe rigors. Physical examination revealed right upper quadrant abdominal pain, and Murphy’s sign was not present. Laboratory tests were significant for leukocytosis (19,800/ul, 91% neutrophils), hyponatremia (122 mmol/l), and hyperglycemia (592 mg/dl). Albumin was low at 1.9 g/dl. Computerized tomography of the abdomen showed a large intrahepatic lesion containing gas (Fig. 1). Given the concern about a pyogenic liver abscess, the patient proceeded to interventional radiology, and percutaneous drainage removed more than 400 ml of purulent material. Klebsiella pneumoniae subsequently grew from both the drainage material and blood cultures. HIV testing returned negative. The patient did well and was discharged home with oral antibiotics and a hepatic drain on hospital day 10. Figure 1 Computerized tomography of the abdomen showing a large intrahepatic lesion containing gas. The prevalence of Klebsiella pneumoniae as a pathogen in hepatic abscesses is rising in Asian countries, particularly in Japan and Taiwan.1 Patients with diabetes, alcoholism, or cancer are at increased risk. In contrast to other pyogenic hepatic abscesses, Klebsiella hepatic abscesses are usually solitary and monomicrobial.2 Early drainage is associated with improved outcomes.3

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture - proven case reported in Brazil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.

Intrapleural Urokinase in the Treatment of Loculated Pleural Effusions

The purpose of this study was to assess the value of intrapleural urokinase (UK) instillations in enhancing tube drainage of loculated, complex pleural effusions. Tube thoracostomy has variable success in the treatment of complex pleural effusions, with limitations because of viscous fluid, improper tube position or kinking, and, most importantly, loculation. In the past, intrapleural administration of streptokinase has been used to lyse locules. In this study, eight patients with nine loculated pleural processes were treated with intrapleural instillations of UK. Six patients had previously undergone unsuccessful conventional tube drainage. Loculation was suggested by persistent fluid despite an adequate trial of simple drainage, radiographic demonstration of septation, or drainage of a volume of fluid far less than expected by a computed tomography scan. After instillation of a UK solution, the tubes were clamped for 30 to 180 min and then placed back to suction. Five pleural cavities with disease 6 to 18 days old showed complete resolution, and clinical improvement occurred. Three pleural processes showed improvement and one showed no improvement, with disease ranging from 23 days to 3 months. No complications were seen. These results suggest that UK instillations may enhance tube drainage of loculated pleural fluid in the early phase, before fibrosis has developed.

The ??Hot Halo?? Sign

The authors report a patient with diffuse pyogenic pericarditis and focal myoendocarditis initially detected using In-111 WBC scintigraphy. The patient was in septic shock after hemodialysis for the treatment of chronic renal failure. This was preceded by clinical signs and symptoms of pericarditis thought to be viral in nature. Initial investigations found no septic focus, and the patient was referred for In-111 WBC scintigraphy. This revealed a striking "halo" of increased activity around the heart, strongly suggesting bacterial pericarditis. A subsequent pericardiocentesis yielded 400 ml of purulent material, confirming the diagnosis.

A rat model of unilateral utero-tubo-ovarian abscess.

Unilateral (utero-tubo-ovarian) abscesses were produced in rats with Bacteroides fragilis in pure culture. One horn of the rat's bicornuate uterus was ligated, and the inoculum of B. fragilis was placed in the uterine horn above the point of ligation. The 50% infecting dose (ID50) of B. fragilis was approximately 10(5) colony forming units (cfu). When harvested the abscesses contained up to 10(8) cfu of B. fragilis in pure culture as well as many white blood cells. Abscesses were 2-3 cm in length and contained 0.5-1.5 ml of purulent material. The oxidation-reduction potential (Eh) of the abscesses ranged from -230 to -323 millivolts. Abscess formation was comparable in all four phases of the estrous cycle. In rats treated with depoestradiol (to create a high-estrogen state), the rate of growth and size of the abscesses (3-5 cm in length and 2-3 ml of purulent material) were greater than in untreated rats.