Primary Abscess Research Articles

A Case of Primary Intraventricular Brain Abscess in a Child: A Challenge to Conquer

Primary intraventricular brain abscess is a rare entity. Not many cases are reported yet. Moreover, proper guidelines for the treatment, conservative treatment or surgery, has not yet been established. Its outcome is also unpredictable and usually poor.We present a 11-year-old girl with wide spread intraventricular brain abscess. There was no obvious cause for the abscess formation. Cardiac status was normal by history and ECHO. She was treated surgically with external ventricular drainage (EVD). There was significant improvement after EVD. Intraventricular flushing was done with the solution of injection Gentamycin and hydrocortisone. However, the patient expired while planned for discharge from the hospital due to sudden cardiac arrest.A bigger study is needed to assess the various factors of intraventricular brain abscess including epidemiology, treatment, outcome etc in the Nepalese context.Nepal Journal of Neuroscience 12:88-90, 2015

The emerging problems of Klebsiella pneumoniae infections: carbapenem resistance and biofilm formation.

Klebsiella pneumoniae is an opportunistic pathogen that commonly causes nosocomial infections in the urinary tract, respiratory tract, lung, wound sites and blood in individuals with debilitating diseases. Klebsiella pneumoniae is still a cause of severe pneumonia in alcoholics in Africa and Asia, and the predominant primary pathogen of primary liver abscess in Taiwan and Southeast Asia, particularly in Asian and Hispanic patients, and individuals with diabetes mellitus. In the United States and Europe, K. pneumoniae infections are most frequently associated with nosocomial infections. The emergence of antibiotic-resistant strains of K. pneumoniae worldwide has become a cause of concern where extended-spectrum β-lactamases (ESBLs) and carbapenemase-producing strains have been isolated with increasing frequency. The pathogen's ability to form biofilms on inserted devices such as urinary catheter has been proposed as one of the important mechanisms in nosocomially acquired and persistent infections, adding to the increased resistance to currently used antibiotics. In this review, infections caused by K. pneumoniae, antibiotic resistance and formation of biofilm will be discussed.

Invasive liver abscess syndrome caused by Klebsiella pneumoniae with definite K2 serotyping in Japan: a case report.

BackgroundKlebsiella pneumonia is a well-known human pathogen, and recently, a distinct invasive syndrome caused by K. pneumoniae serotypes K1 and K2 has been recognized in Southeast Asia. This syndrome is characterized by primary liver abscess and extrahepatic complications resulting from bacteremic dissemination. We report the first adult case of primary liver abscess caused by the definite K2 serotyped pathogen, with endogenous endophthalmitis in Japan.Case presentationA 64-year-old woman was admitted to a nearby hospital for a high fever and diarrhea. She had visual loss of her right eye, renal dysfunction, and thrombocytopenia within 24 h from admission. She was transferred to our institution. On admission, she had no alteration of mental status and normal vital signs; however, she had almost complete ablepsia of the right eye. Laboratory data showed severe inflammation, liver dysfunction, thrombocytopenia, an increased serum creatinine level, and coagulopathy. Computed tomography showed a low density area in the right lobe of the liver. Invasive liver abscess syndrome probably caused by K. pneumonia was highly suspected and immediately administered broad-spectrum antibiotics for severe sepsis. Concurrently, endogenous endophthalmitis was diagnosed, and we performed vitrectomy on the day of admission. The blood culture showed K. pneumoniae infection. Percutaneous drainage of the liver abscess was also performed. Although she was discharged in a good general condition on day 22, she had complete ablepsia of the right eye. The K2A gene was detected by polymerase chain reaction (PCR), which is consistent with the K2 serotype. PCR was also positive for the virulence-associated gene rmpA. Final diagnosis was invasive liver abscess syndrome caused by K2 serotype K. pneumonia.ConclusionsAlthough the primary liver abscess caused by K. pneumoniae with a hypermucoviscous phenotype is infrequently reported outside Southeast Asia, physicians should recognize this syndrome, and appropriate diagnosis and treatment is essential for saving patients’ lives and preserving organ function, especially for visual acuity.

Changing patterns in the management of Colonic Trauma

Recent prospective studies have recommended primary repair for all colonic trauma. We evaluate the changing patterns given these recommendations and assess our results of primary repair. This prospective study was conducted on 63 patients with colonic trauma received over a year from July 2000 to June 2001. Morbidity was defined as failure of a primary repair, abscess, fistula, wound dehiscence, sepsis, and organ failure. Primary repairs were performed in 28 patients and colostomy was done in 35 patients. Prolonged mean hospital stay and more incidences of postoperative complications occurred in colostomy group. It was therefore, concluded that primary repair of colon should be adapted as a standard procedure. Colostomy should be reserved for patients with a prolonged delay to surgery, severe blood loss, and gross faecal contamination or associated with multiple organ injuries.

Surgical Management of Coexisting Primary Splenic Abscess and Lymphoma: Case Report and Review of Literature

We present an extremely rare case of combined splenic abscess and B-cell lymphoma in a patient who was initially admitted for congestive heart failure. Due to its non-specific clinical picture, the final diagnosis was challenging. The patient was initially conservatively managed with antibiotics and percutaneous drainage of the abscess and then definitively managed with a splenectomy. This is the first case described with both pathological processes present simultaneously. J Curr Surg. 2016;6(3-4):73-74 doi: https://doi.org/10.14740/jcs304w

"Primary" nocardial brain abscess in a renal transplant patient

BackgroundIntracranial abscesses are rare among transplant recipients, and Nocardia is responsible for less than 2 % of them. Nocardiosis, a chronic infection and is difficult to treat. Primary infection involves lungs and eventually disseminates. Primary nocardial abscesses are rare and we report a case from Sri Lanka.Case presentationA 38 year old Sri Lankan, who has received his 2nd ABO matched live donor transplantation, which was complicated with perinephric hematoma and massive transfusion syndrome. He presented with fever, worsening headache and papilledema. An urgent magnetic resonance image (MRI) showed an occipital abscess with midline shift. Craniotomy and drainage followed by 3 week course of imipenem and levofloxacin, which rendered him symptom free. After 12 months he has stayed recurrence free. Imaging and bacteriology of the respiratory tract failed to demonstrate Nocardia infection.ConclusionIsolated (Primary) nocardial brain abscess are rare, and have an excellent response to medical therapy. We achieved a good response from a relatively short course of antibiotics (not using sulfonamides, due to allergy), where long courses of antibiotic had been the norm.

Clinical and molecular characteristics of bloodstream infection caused by K. pneumonia

Objective To investigate the clinical features and molecular characteristics of bacteremia caused by K. pneumoniae and study on the differences between classical and hypervirulent K. pneumonia(hvKP). Methods The clinical features of 70 cases of K. pneumoniae bacteremia collected from Beijing Chaoyang Hospital from 2008 to 2012 were retrospectively analyzed. The patients were identified according to the records from the Clinical Microbiology Department. Patients' data were obtained from medical records. The molecular characteristics of the K. pneumoniae strains were also studied using PCR, multilocus sequence typing and pulsed field gel electrophoresis(PFGE) methods. Data were analyzed using the statistical package SPSS for windows version 17.0. For categorical data, different groups were compared using the Chi-square test to analyze the quantitative variables. P≤0.05 was considered to be statistically significant. All susceptibility data were analyzed using Whonet, version 5.6. Results The hvKP was identified from 31.4% of the patients with K. pneumoniae bacteremia, which displayed 4 serotypes (K1, K2, K20, and K57). About 40.9% (9/22) hypervirulent strains were isolated from patients without underlying diseases, while 95.8% (46/48) of the classic K. pneumoniae infections were found in patients with the presence of one or more underlying diseases. More hvKP positive patients (95.5%, 21/22) had community-acquired infections compared with classical K. pneumonia (cKP) infected patients (35.4%, 17/48). There was a significant difference between these two groups (χ2=21.912, P<0.001). Two ESBLs-producing hvKP strains were found. The 22 hvKP isolates had 14 different PFGE patterns, among which 6 isolates (patients with primary liver abscess) shared similar PFGE patterns. Conclusions The emerging hvKP was prevalent in patients with severe community-acquired infections in healthy individuals. Two ESBLs-producing hvKP strains were identified. Drug resistance had a rising trend, which called for more attention in clinical settings. (Chin J Lab Med, 2015, 38: 627-631) Key words: Liver abscess; Community-acquired infections; Klebsiella pneumoniae; Virulence

Management of Lung Abscess

A lung abscess is an infectious pulmonary disease characterised by the presence of a pus-filled cavity within the lung parenchyma. The content of an abscess often drains into the airways spontaneously, leading to an air-fluid level visible on chest X-rays and CT scans. Primary lung abscesses occur in patients who are prone to aspiration or in otherwise healthy individuals; secondary lung abscesses typically develop in association with a stenosing lung neoplasm or a systemic disease that compromises immune defences, such as AIDS, or after organ transplantation. The organisms found in abscesses caused by aspiration pneumonia reflect the resident flora of the oropharynx. The most commonly isolated organisms are anaerobic bacteria (Prevotella, Bacteroides, Fusobacterium, Peptostreptococcus) or streptococci; in alcoholics with poor oral hygiene, the spectrum of pathogens includes Staphylococcus aureus, Streptococcus pyogenes and Actinomyces. Chest radiography and computed tomography (CT) are mandatory procedures in the diagnostic algorithm. Standard treatment for a lung abscess consists of systemic antibiotic therapy, which is based on the anticipated or proven bacterial spectrum of the abscess. In most cases, primary abscesses are successfully treated by calculated empiric antibiotic therapy, with an estimated lethality rate of less than 10 %. Secondary abscesses, despite targeted antimicrobial therapy, are associated with a poor prognosis, which depends on the patient's general condition and underlying disease; lethality is as high as 75 %. Negative prognostic factors are old age, severe comorbidities, immunosuppression, bronchial obstruction, and neoplasms. Surgical intervention due to failure of conservative treatment is required in only 10 % of patients, with a success rate of up to 90 % and postoperative mortality rates ranging between 0 and 33 %. Treatment success after endoscopic or percutaneous drainage is achieved in 73 to 100 % of cases, with an acceptable mortality rate (0-9 %).

Eight cases of invasive Klebsiella pneumoniae infection from a public teaching medical institution in the USA

Background: Klebsiella pneumoniae is a common human bacterial pathogen known to cause invasive infections such as primary liver abscesses, necrotizing fasciitis, meningitis and endophthalmitis with bacteraemia among patients in eastern Asia. Over the last decade, geographical spread and emergence of invasive K. pneumoniae infection has occurred in the USA. The majority of reported cases involve males with diabetes mellitus, of Asian ethnicity and who have recently travelled to Asia. Results: We identified eight invasive cases with liver abscesses and necrotizing fasciitis at our institution. The most common risk factors associated with invasive infection were male gender and diabetes mellitus, which is consistent with other reported cases. However, Caucasians and Hispanics represented the majority of invasive disease (n = 7), and history of recent travel to Asia was not identified in any of the cases. Discussion: Further studies with larger cohorts involving multiple healthcare institutions in the USA are warranted to confirm these two unusual characteristics of infection. Healthcare professionals should be informed of the possible association between K. pneumoniae and invasive disease in male diabetic persons of non-Asian descent and without recent travel to Asia in the USA.

Primary pyogenic spinal epidural abscess: How late is too late and how bad is too bad? – A study on surgical outcome after delayed presentation

Spinal epidural abscess is a rare clinical entity with considerable morbidity. Even with prompt diagnosis and treatment, many patients are left with persistent residual neurological deficits. The present study details the outcome in 23 patients of primary pyogenic spinal epidural abscess, addressing the outcome following late presentation at a neurological facility. At presentation only 2 patients had relatively preserved neurological status. Eleven patients were paraplegic. All the patients underwent laminectomy and evacuation of abscess. A good functional outcome was observed in almost half of the patients, and there was a significant reduction in the number of the patients with severe disability. Factors influencing the outcome are described in this study.

Capsular Polysaccharide Is Involved in NLRP3 Inflammasome Activation by Klebsiella pneumoniae Serotype K1.

Klebsiella pneumoniae (strain 43816, K2 serotype) induces interleukin-1β (IL-1β) secretion, but neither the bacterial factor triggering the activation of these inflammasome-dependent responses nor whether they are mediated by NLRP3 or NLRC4 is known. In this study, we identified a capsular polysaccharide (K1-CPS) in K. pneumoniae (NTUH-K2044, K1 serotype), isolated from a primary pyogenic liver abscess (PLA K. pneumoniae), as the Klebsiella factor that induces IL-1β secretion in an NLRP3-, ASC-, and caspase-1-dependent manner in macrophages. K1-CPS induced NLRP3 inflammasome activation through reactive oxygen species (ROS) generation, mitogen-activated protein kinase phosphorylation, and NF-κB activation. Inhibition of both the mitochondrial membrane permeability transition and mitochondrial ROS generation inhibited K1-CPS-mediated NLRP3 inflammasome activation. Furthermore, IL-1β secretion in macrophages infected with PLA K. pneumoniae was shown to depend on NLRP3 but also on NLRC4 and TLR4. In macrophages infected with a K1-CPS deficiency mutant, an lipopolysaccharide (LPS) deficiency mutant, or K1-CPS and LPS double mutants, IL-1β secretion levels were lower than those in cells infected with wild-type PLA K. pneumoniae. Our findings indicate that K1-CPS is one of the Klebsiella factors of PLA K. pneumoniae that induce IL-1β secretion through the NLRP3 inflammasome.

Primary Nocardia farcinica Brain Abscess With Secondary Relapsing Meningitis in an Immunocompromised Patient

Nocardiosis is an opportunistic infection primarily affecting immunocompromised patients. Central nervous system (CNS) involvement in the form of cerebral abscesses may be a complication of nocardia infection. Nocardia farcinica , in particular, is believed to disseminate the CNS more often than other nocardia species, being associated with antibiotic resistance and therefore higher mortality. We describe the first case of a patient with relapsing meningitis caused by N. farcinica . A 61-year-old Caucasian man was admitted for evaluation of fever, headache and confusion. Magnetic resonance imaging of the brain revealed cerebral abscesses and examination of the cerebrospinal fluid (CSF), polymorphonuclear count, elevated protein and hypoglycorrhachia. CSF cultures were negative, while multiplex polymerase chain reaction showed Staphylococcus aureus . The patient received vancomycin/meropenem and later, because he was still febrile, with symptoms from the CNS, linezolid/meropenem, in which he responded well. During the following months, he had to discontinue linezolid because of myelosuppression with subsequent relapses of meningitis. In such a relapse, the patient was admitted for reevaluation. CNS cultures grew N. farcinica , susceptible to linezolid, trimethoprim/sulfamethoxazol and ceftriaxone. He was discharged on trimethoprim/sulfamethoxazole for 12 months. This is the first reported case of relapsing meningitis caused by N. farcinica . It highlights, on the one hand, the importance of the prolonged treatment in relapse’s prevention and on the other, the limited value of linezolid as prolonged treatment due to its long-term toxicities. J Med Cases. 2015;6(7):304-306 doi: http://dx.doi.org/10.14740/jmc2157w

Abstract #1223: Primary Liver Abscess and Septic Pulmonary Emboli in a Diabetic Patient: a New Invasive Syndrome.

Abstract #1223: Primary Liver Abscess and Septic Pulmonary Emboli in a Diabetic Patient: a New Invasive Syndrome.

Primary iliopsoas abscess in a diabetic patient

A 69-year-old man with a history of type 2 diabetes, cerebral infarction, lumbar spinal canal stenosis, and herniated disk presented with progressive left-sided lower back pain over a few days. He had no history of trauma or recent skin infection. On clinical examination, he had high-grade fever (38·2°C) and a psoas posture. Laboratory showed leucocytosis (white-cell count 11·1 × 109 cells per L) and raised C-reactive protein concentration (352·39 nmol/L). Contrast-enhanced CT of the abdomen after plain CT showed a swollen left iliopsoas muscle containing fluid (figure A, arrows).

Isolated spontaneous primary tubercular erector spinae abscess: a case report and review of literature.

Isolated spontaneous primary tubercular erector spinae abscess in an immunocompetent patient is very rare. Here, we report such a case of 21-year-old female, which was successfully managed with timely diagnosis and intervention. Isolated primary tubercular abscess of erector spinae is a rare differential diagnosis of low back pain; however, it must be suspected in an endemic region for tuberculosis, especially when raised erythrocytic sedimentation rate and C-reactive protein are present. Excision along with anti tubercular therapy proved to be a successful strategy in our patient.

Clinical characteristics of lung abscess in children: 15-year experience at two university hospitals.

PurposeInformation on the clinical features of lung abscess, which is uncommon in children, at hospitalizationis helpful to anticipate the disease course and management. There is no report concerning lung abscess in Korean children. We aimed to identify the clinical characteristics of pediatric lung abscess and compare the difference between primary and secondary abscess groups.MethodsThe medical records of 11 lung abscess patients (7 males and 4 females) from March 1998 to August 2011 at two university hospitals were retrospectively reviewed. The clinical characteristics, symptoms, underlying disease, laboratory and radiologic findings, microbiological results, and treatments were examined.ResultsSix patients had underlying structural-related problems (e.g., skeletal anomalies). No immunologic or hematologic problem was recorded. The mean ages of the primary and secondary groups were 2.4 and 5.3 years, respectively, but the difference was not statistically significant. The mean length of hospital stay was similar in both groups (22.8 days vs. 21.4 days). Immunologic studies were performed in 3 patients; the results were within the normal range. Most patients had prominent leukocytosis. Seven and 4 patients had right and left lung abscess, respectively. Staphylococcus aureus, Streptococcus pneumoniae, and antimycoplasma antibodies were detected in both groups. Two patients with primary lung abscess were administered antibiotics in the absence of other procedures, while 8 underwent interventional procedures, including 5 with secondary abscess.ConclusionThe most common symptoms were fever and cough. All patients in the primary group were younger than 3 years. Structural problems were dominant. Most patients required interventional procedures and antibiotics.

Author Response: Isolated Spontaneous Primary Tubercular Erector Spinae Abscess: A Case Report and Review of Literature.

We appreciate readers for providing their insightful comments and detailed clarification on our article. They have drawn our attention towards the case reported by Indudhara et al. [1]. In our article we have mentioned that there exists one report [2] on isolated spontaneous primary tubercular erector spinae abscess until date. In our report, the usage of the word primarily signifies this case is important because it is 'primary' tubercular erector spinae abscess without any predisposing conditions such as immunocompromised state, any steroid or other drugs intake and presence of tuberculosis at any other body parts. We would like to mention here that the case reported by Indudhara et al. [1] was on renal transplant recipient with tubercular pyomyositis of left erector spinae muscle. This is totally a different case scenario from our case [3], as patient was a renal transplant recipient and had immuno-compromised status. It has already been documented in the literature that risk of dissemination and extraskeletal tuberculosis is more in immunocompromised patients [4]. In our case [3], the patient was immunocompetent young female, who had spontaneous onset of lower back pain. Moreover, our case signifies that magnetic resonance imaging is non-invasive diagnostic modaltiy of choice in such cases as it gives much better details of the diseases affecting soft tissues. We do agree that injection of muscular tissue by the tubercular bacilli without coexistence of active skeletal and extraskeletal tuberculosis is an event of rare occurrence. However, anti-tubercular multi drug therapy with or without surgical intervention (aspiration/incision and drainage) is the treatment of choice and has shown consistent results in the past [1,2,3,5]. We do appreciate the interest, which our readers have shown in our work and stressed appropriately for the awareness in the medical fraternity about the diagnosis and treatment of musculo-skeletal tuberculosis, as it is quite a rare entity in present world medical practice.

Erector Spinae Tubercular Abscess.

Dear Editor, We have read with great interest the case report entitled, Isolated Spontaneous Primary Tubercular Erector Spinae Abscess: A Case Report and Review of Literature in the issue of Asian Spine J 2015;9(2):276-280 doi: 10.4184/asj.2015.9.2.276 and we would like to congratulate the authors on their management of the case. However, we would like to make some comments, which we believe will advance the potential contribution of this study [1]. 1. The authors state that until date, there has been only one report [2] on isolation of spontaneous primary tubercular erector spinae abscess [1]. We agree with the authors but we would like to draw attention towards one additional case report related with erector spinae tubercular abscess in a renal-transplant recipient [3]. Indudhara et al. [3] have also reported a case of tuberculous pyomyositis involving the left erector spinae muscle but with no other manifestations of tuberculosis. The diagnosis was suspected from the CT scan appearance and confirmed by microscopy and culture of the pus. In addition, infection was cured through surgical incision and drainage along with antituberculosis therapy [3]. Soft-tissue tuberculosis in renal-transplant recipients has only been reported twice: one patient with isolated pyomyositis involving the erector spinae muscle [3], and one with olecranon bursitis [4]. 2. Muscle involvement without coexisting active skeletal or extraskeletal tuberculosis is a very rare form of extrapulmonary tuberculosis, which manifests with different presentations such as isolated muscle mass, tubercular myositis, isolated muscular abscess and tubercular pyomyositis [5]. The rarity of muscle involvement in tuberculosis has been attributed to various reasons such as a high lactic acid concentration, lack of reticuloendothelial/lymphatic tissue, abundant blood supply, and the highly differentiated state of muscle tissue [6]. Pyomyositis is the least common presentation of extraspinal musculoskeletal tuberculosis and most of the cases in the literature have shown the involvement of a single site [7]. 3. The treatment of antitubercular multidrug therapy (isoniazid [INH], rifampin [RIF], ethambutol [EMB], and pyrazinamide [PZA]) should be started as early as possible, in case histology or culture proves the diagnosis and other noninfectious pathology has been excluded by clinical examination, imaging or laboratory investigations. Soft tissue and muscular tuberculosis can be treated with aspiration and a full course of anti-tuberculous therapy. Recurrence could occur in the absence of a complete course of anti-tuberculous therapy [7]. Consequently, tuberculosis, so called 'The Great Imitator', may present with a variety of nonspecific signs and symptoms. We would like to draw attention to the atypical presentations of tuberculosis that should be kept in mind. A high index of suspicion is necessary for the diagnosis and early detection of rare types of tuberculosis may lead to proper management of patients. Again we appreciate the authors on work which adds to our knowledge of that an atypical presentation of tuberculosis has staged a remarkable comeback in today's world.

Primary Ovarian Abscess Arising Spontaneously within an Endometrioma: A Rare Case

We report a very rare case of de novo abscess formation inside an endometrioma without any prior intervention in a 32-year-old woman. She presented with acute abdominal pain and persistent high-grade fever. A lump was palpable and tender and showed features of endometrioma on ultrasound. Laparotomy was conducted, as her clinical condition deteriorated despite broad spectrum antibiotics, and her fever did not subside. Thick foul-smelling pus was drained from the endometrioma, and the abscess wall was removed, followed by cystectomy. The patient improved markedly and did well in the postoperative period.

Primary Nocardia farcinica Brain Abscess With Secondary Relapsing Meningitis in an Immunocompromised Patient

Primary Nocardia farcinica Brain Abscess With Secondary Relapsing Meningitis in an Immunocompromised Patient