Management of Pyogenic Liver Abscess in Neonates

Abstract

A 35-day-old Saudi boy developed respiratory distress from bilateral pneumonitis due to meconium aspiration. He required ventilation for 8 days, and an umbilical vein catheterization for 2 days. He had thrombocytopenia of 16 × 103/cmm. Leukocytosis of 32 × 103/cmm and Hgb of 15.3 × g/L. Two days later he developed fresh signs of sepsis with hepatosplenomegaly, abdominal distension, and generalized erythematous rash. At this stage he had Hgb 15.3 g/L, WBC 45 × 103/cmm and platelet count of 32 × 103; liver enzymes were within normal limits, and PT and PTT were prolonged > 100 sec. Culture of blood, cerebrospinal fluid, and urine were sterile; but that of umbilical venous catheter tip grew Staph epidermidis sensitive to cephalothin, cloxacillin and cefatoxin. The boy was started on cefatoxin.Because of the continuing signs of sepsis, an ultrasound and CT scan of the abdomen were done. The results showed a lesion measuring 2.5 cm consistent with a liver abscess (Figure 1). He was referred to our hospital a week later for further management of the liver abscess.On examination the infant looked healthy, alert, and active, with no dysmorphic feature, except premature closure of coronal suture, with small anterior fontanelle. The liver was palpable 2 cm below the costal margin. The spleen was just palpable. Hgb was 13.2 g/L, WBC 16.8 × 103, platelets 147 × 103/cmm. PT, PTT, and liver enzymes were within normal limits. A radioisotope, sonographic, and CT scanning of the abdomen revealed markedly decreased liver abscess.Because of favorable clinical and radiological data, it was decided to continue the conservative management, using a combination of Cephalothin, Cefatoxin and Cloxacillin. Three weeks later, chest x-rays and CT scanning showed a normal lung and complete resolution of the liver abscess. Antibiotics were stopped and the boy discharged in good health, which continued to be evident when the patient was seen a month later.Pyogenic liver abscess is rare in children, and rarer still in neonates. In an extensive review of literature, Moss and Pysher [4] found only 24 reported cases and added 13 from their institution; but the prevalence will remain unknown, because autopsies are not done routinely, and many cases will escape diagnosis. The diagnosis is often missed, or delayed, because of the absence of specific signs or symptoms; these are usually the result of sepsis [3,4]. Out of 13 reported cases, only one was recognized before death [4]. The delay of diagnosis in our case, despite the presence of many risk factors, such as umbilical vein catheter [5], asphyxia neonatorum and sepsis, was due to the absence of specific signs and symptoms. Moreover, the presence of aspiration pneumonitis overshadowed the true lesion. Fever, as a symptom, may not be specific of hepatic lesion. This is particularly true in the neonates reported by Moss and Pysher [4], where only 3 out of thirteen neonates were significantly pyrexial. This is in contrast with other reports, where a number of children older than one month were febri...