Tropical Doctor

http://tdo.sagepub.com/

Causative agents of liver abscess in HIV-seropositive patients: a 10-year case series in Thai
hospitalized patients
Viroj Wiwanitkit
Trop Doct 2005 35: 115
DOI: 10.1258/0049475054036904

The online version of this article can be found at:

http://tdo.sagepub.com/content/35/2/115

Published by:

http://www.sagepublications.com

On behalf of:
THET

Additional services and information for Tropical Doctor can be found at:

Email Alerts: http://tdo.sagepub.com/cgi/alerts

Subscriptions: http://tdo.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Apr 1, 2005

What is This?

Downloaded from tdo.sagepub.com at Queen's University on October 19, 2014

Case Series and Case Reports
Causative agents of liver
abscess in HIV-
seropositive patients: a
10-year case series inThai
hospitalized patients
Viroj Wiwanitkit MD
Department of Laboratory Medicine, Faculty of Medicine,
Chulalongkorn University, Bangkok,Thailand 10330
Correspondence to: Dr Viroj Wiwanitkit
Email: Virog.W@Chula.ac.th
TROPICAL DOCTOR 2005; 35: 115–117
SUMMARY Liver abscess is an important tropical gastro-
intestinal disorder. HIV seropositive patients show relative
immunosuppression and are more susceptible to infection,
including liver abscess.This retrospective case review was
made on 23 patients who were diagnosed as HIV seropo-
sitive with liver abscess in Bangkok,Thailand.We demon-
strated the high rate of amoebic liver abscess in our series
(17.4%) from fresh smear with five cases of tuberculosis
and one case of Nocardosis.The rates of positive bacterial
culture were 17.4% from blood and 47.8% from pus. Gram-
negative aerobes were the major abscess pathogens in our
series. Among Gram-negative aerobes, Klebsiella was the
most significant microorganism, followed by Escherichia
coli and Pseudomonas aeruginosa.
Introduction
Significant differences exist in the prevalence of most
gastroenterological emergencies in tropical compared with
temperate countries.1 Both ethnic and environmental
factors are relevant, often clearly defined geographically.
Liver abscess is an important tropical gastrointestinal
disorder.1,2 The aetiology of liver abscess is mainly
pyogenic or amebic.
There are only a few studies concerning the causative
pathogens of liver abscess among the HIV-seropositive
patients.3 Generally, patients who are HIV seropositive
show immunosuppression and are more susceptible to
infection, including liver abscess.4,5 However, there are
only a few reports concerning the liver abscess among the
HIV-seropositive patients.4,3,6 Nevertheless, most of those
studies came from temperate countries, where the
prevalence of tropical infection is not as high as the
tropical ones. The purpose of this retrospective study was
to study the causal pathogens of liver abscess in Thai
HIV-seropositive patients. Of interest, some pathogens
prevailing in the tropical countries such as Mycobacterial
tuberculosis and Entamoeba histolytica can be identified as
the common causative agents for liver abscess in HIV-
seropositive patients in our setting.
Tropical Doctor April 2005, 35
Downloaded from tdo.sagepub.com at Queen's University on October 19, 2014
Materials and methods
This study is a retrospective descriptive study. The
retrospective case review was made on hospitalized
patients who were HIV seropositive with liver abscess at
the King Chulalongkorn Memorial Hospital, Bangkok,
Thailand. This study focused on a 10-year period, from
January 1992 to December 2001. Concerning our study,
liver abscess was diagnosed according to both the
presentation of the abscess cavity on hepatic ultrasound
and/or computerized tomography scans, and according to
pus drained from the cavity during needle aspiration or
surgery.
The review of the patients’ medical records during this
period identified cases with a conclusive confirmed
diagnosis for further analysis. The data from the
discharge summary of these patients were then recorded
including their age and sex, as well as the final diagnosis.
Clinical information collected included laboratory data,
location and number of abscesses, causal pathogens,
blood and pus culture. All microbiological tests in this
study were performed at the Bacteriology Laboratory of
the hospital.
Results
Twenty-three cases of HIV-seropositive patients with liver
abscess were included in this study. There were 10 men
(56.5%) and 13 women (43.5%), with a mean age of
45.09716.74 years (range, 25–78 years). In these 23
patients with liver abscesses, the abscesses were in the
right lobe in 17 patients (73.9%), in the left lobe in four
(17.4%), and in both lobes in two (8.7%). Eighteen
patients (78.3%) had single abscess and five patients
(21.7%) had multiple abscesses.
In all 23 patients, the aspirated pus was examined
microscopically by fresh smear and revealed four cases of
E. histolytica infection. All cases presented the strong
positive titre (>1:1024) for E. histolytica indirect
haemagglutination (IHA) test. Of interest, neither tro-
phozoites nor cysts of E. histolytica in stool were found in
stool samples from these four patients. Apart from the
fresh smear, the acid-fast and modified acid-fast stains
were also performed and revealed five cases of TB and one
case of nocardosis. These six cases were confirmed
diagnosis by special culture test.
In addition, blood and pus cultures were performed in
all subjects. The causative pathogens from culture in
abscess and blood are listed in Table 1. Of the 23 patients
with abscesses, 11 had positive pus culture results (47.8%)
and four had positive blood culture results (17.4%).
All the 11 cases with positive pus culture had mono-
microbial pus culture results. The four cases with positive
blood culture had monomicrobial blood culture results.
The corresponding monomicrobial species were isolated
from blood and pus cultures in four patients. Seven cases
of monomicrobial isolation were only identified from pus
cultures.
In conclusion, the causative agents for liver abscesses
could be identified in 21 cases, 10 from microscopical
examination and 11 from culture study (Table 2). The
115
Case Series and Case Reports

Table 1 Microorganisms detected by the bacterial culture of pus and opportunistic infection among the HIV seropositive
blood of in 23 HIV- seropositive patients with liver abscesses patients. A review of the literature indicates there is no
typical clinical presentation. An early diagnosis of this
Microorganism Pus (n=23) Blood (n=23) disease is necessary, especially because this is a treatable
Gram-negative aerobe condition even in patients with AIDS.6
Klebsiella pneumoniae 4 3 In addition, a case of nocardiosis can be identified by
Escherichia coli 2 0 microscopical identification of the pus stain. This
Pseudomonas aeruginosa 2 0 causative pathogen of liver abscess is rare and found in
Gram-positive aerobe the immunocompromised host.11,12 This case gave a
Staphylococcus aureus 1 1 negative result from routine bacterial culture, but
provides a positive culture as confirmation from special
Gram-negative anaerobe culture. Conclusively, the causative pathogen can be
Bacteroides fragilis 2 0
identified in 10 cases (38.6%) in our series by micro-
Gram-positive anerobe 0 0 scopical examination.
Negative culture result* 12 19 In our series, the rates of positive culture were 17.4%
*Of these negative culture cases, four cases were identified to have Entamoeba from blood and 47.8% from pus, while in HIV-
histolytica infection, five were identified to have Mycobacterial tuberculosis seronegative patients the rates were reported to be
infection and one case was identified to have nocardiosis 40–60% from blood cultures and 73–92% from pus
cultures.10,13,14 According to the culture results, Gram-
negative aerobes were the major abscess pathogens
Table 2 The causative agents of liver abscesses in 23 HIV-seropositive (75.0% and 72.7% in blood and pus cultures, respectively)
patients in our series. Among gram-Negative aerobes, Klebsiella
pneumoniae (36.4% of pus culture) was the most
Agents No. of cases (%) significant microorganism, followed by Escherichia coli
Can be identified 21 (91.3) (18.2%) and Pseudomonas aeruginosa (18.2%). These
Mycobacterial tuberculosis 5 (21.8) finding agrees with the previous reports in HIV-
Entamoeba histolytica 4 (17.4) seronegative patients.15,16
Klebsiella pneumoniae 4 (17.4)
Escherichia coli 2 (8.7)
According to our study, it was easier to obtain culture
Pseudomonas aeruginosa 2 (8.7) results from pus than from blood. Furthermore, the
Bacteroides fragilis 2 (8.7) microscopical examination of pus can provide additional
Staphylococcus aureus 1 (4.3) diagnosis as already described. Thus, aspiration of the
Nocardia spp 1 (4.3)
abscess for culture is an essential procedure in a HIV-
Cannot be identified* 2 (8.7) seropositive patient with liver abscess.
Most of the causative agents of liver abscesses in our
*These two cases were diagnosed as pyogenic liver abscess due to the respon-
siveness to try treatment as pyogenic liver abscesses
HIV-seropositive patients are similar to those in general
population.15–20 However, a significant high rate of
tuberculous abscess (21.7%) can be detected in this study.
other two cases with unknown causative pathogen were Indeed, this cause of liver abscess is uncommon and rarely
tried treatment as pyogenic liver abscess and the patients detected in the previous reports.4,3,6
improved. In conclusion, the pyogenic liver abscess is the most
common group of liver abscess in our series. Concerning
the causative agent of liver abscess in our HIV-seroposi-
Discussion tive patients, the three most common organisms are
There are only a few reports concerning the liver abscess M. tuberculosis, E. histolytica and K. pneumoniae. The
in HIV-seropositive patients. In our series, the abscesses tropical infections such as TB and amoebiasis are
were located predominantly in the right lobe of the liver important causes of liver abscess in HIV-seropositive
(73.9%), while abscesses were located in the right lobe in patients in our setting.
56% to 72% of HIV-seronegative patients in most
studies.7,8 Concerning the number of abscess, most of References
our patient had single abscess (78.3%). This finding is
similar to the reported characters among the HIV- 1 Cook GC. Gastroenterological emergencies in the tropics.
seronegative patients as well.9 Baillieres Clin Gastroenterol 1999;5:861–86
We can demonstrate the high rate of amoebic 2 Reeder MM. Tropical diseases of the liver and bile ducts.
liver abscess in our series (17.4%). Generally, invasive Semin Roentgenol 1975;10:229–43
amoebiasis as ameobic liver abscess rarely occurs in 3 Liu CJ, Hung CC, Chen MY, et al. Amebic liver abscess and
HIV-seropositive individuals and has not been regarded human immunodeficiency virus infection: a report of three
cases. J Clin Gastroenterol 2001;33:64–8
as a disorder for concomitant HIV infection. One of the
4 Filice C, Brunetti E, Bruno R, Crippa FG. Clinical
possible explanations is the fact that most of the previous
management of hepatic abscesses in HIV patients. Am J
studies were in the temperate countries, which is not the Gastroenterol 2000;95:1092–3
endemic area of amoebiasis.10 Our findings support the 5 Wiselka MJ. A clinical overview of opportunistic infections
observation of Liu that amebic liver abscess can be an in patients with AIDS. Mol Cell Biol Hum Dis Ser 1993;
important gastrointestinal problem for HIV infection in 2:1–22
the Far East.3 6 Pottipati AR, Dave PB, Gumaste V, Vieux U. Tuberculous
We also had five cases of tuberculous liver abscess in abscess of the liver in acquired immunodeficiency syndrome.
our series. The acid-fast organisms can be detected by the J Clin Gastroenterol 1991;13:549–53
direct microscopical examination. All of these five cases 7 Bissada AA, Bateman J. Pyogenic liver abscess: a 7-year
are confirmed to be M. tuberculosis by special mycobac- experience in a large community hospital. Hepatogastroen-
terium culture. Tuberculous liver abscess is an important terology 1991;38:317–20

116 Tropical Doctor April 2005, 35

Downloaded from tdo.sagepub.com at Queen's University on October 19, 2014

 Case Series and Case Reports

8 Branum GD, Tyson GS, Branum MA, Meyers WC. Hepatic oedema but no eye involvement. A cheilitis was present
abscess: changes in etiology, diagnosis, and management. on the lower lip (Figure 2). The areas immediately under
Ann Surg 1990;212:655–62 the nose and under the chin were not affected. The
9 Chou FF, Sheen-Chen SM, Chen YS, Chen MC. Single and cutaneous areas under the clothes (trunk, shoulders, arms,
multiple pyogenic liver abscesses: clinical course, etiology, thighs) were not affected. There was a triangular zone of
and results of treatment. World J Surg 1997;21:384–9 excoriated maculopapules at the V of the neck coinciding
10 Seeto RK, Rockey DC. Pyogenic liver abscess: changes in with the patient’s shirt opening (see Figure 1). The patient
etiology, management, and outcome. Medicine (Baltimore) recalled having developed perioral pruritic lesions after
1996;75:99–113 taking a three-day course of chloroquinine for Plasmo-
11 Raby N, Forbes G, Williams R. Nocardia infection in dium vivax infection six months earlier. This was allegedly
patients with liver transplants or chronic liver disease: her first malaria infection, and she had never taken
radiologic findings. Radiology 1990;174:713–6 choloroquine before that. She was given intravenous
12 Roman HO, Vilar JH, Corrales JL, Lanari Zubiaur FJ.
dexamethasone and chlorpheniramine for three days until
Liver abscess caused by Nocardia. Report of a case. Rev Esp
the quinine treatment was finished. This was followed by
Enferm Dig 1991;80:282–3
topical steroid ointment. After the quinine treatment ended,
13 Shimada H, Ohta S, Maehara M, Katayama K, Note M,
Nakagawara G. Diagnostic and therapeutic strategies of the rash receded rapidly and she was discharged on day 9.
pyogenic liver abscess. Int Surg 1993;78:40–5
14 Vukmir RB. Pyogenic hepatic abscess. Am Fam Physician Discussion
1993;47:1435–41 Given the distribution of the eruption on photoexposed
15 Cheng DL, Liu YC, Yen MY, Liu CY, Shi FW, Wang LS. areas, and its coincidence with quinine treatment, the
Pyogenic liver abscess: clinical manifestations and value of diagnosis of photallergy was made. This is the first case
percutaneous catheter drainage treatment. J Formos Med observed in over 1000 quinine treatments given in the
Assoc 1990;89:571–6 Shoklo Malaria Research Unit clinics.
16 Chiu CT, Lin DY, Wu CS, Chang-Chien CS, Sheen IS, Liaw
YF. A clinical study on pyogenic liver abscess. J Formos
Med Assoc 1987;86:405–12
17 Falaiye JM, Okeke GC, Fregene AO. Amoebic abscess in the
cirrhotic liver. Gut 1980;21:161–3
18 Kladcharoen N, Sittprija S. Liver abscess in Thailand. Chula
Med J 1988;32:677–81
19 Liew KV, Lau TC, Ho CH, et al. Pyogenic liver abscess – a
tropical centre’s experience in management with review of
current literature. Singapore Med J 2000;41:489–92
20 Rustgi AK, Richter JM. Pyogenic and amebic liver abscess.
Med Clin North Am 1989;73:847–58

Photoallergy to quinine
Mathieu Nacher MD PhD1
Rose McGready MD PhD2
Carit Lermoo2 Jatee Wichiponpiboon2
Franc- ois Nosten MD PhD2
1
Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi
Road,10400, Bangkok; 2Shoklo Malaria Research Unit, 736/2 Intra-
kiri Road, PO Box 46, Mae Sod, 63110,Tak,Thailand
Correspondence to: Dr Mathieu Nacher, CISIH, Centre Hospi-
talier de Cayenne, Avenue des Flamboyants, 97300 Cayenne,
Guyane
Email: m_nacher@lycos.com Figure 1 A maculopapulovesicular rash caused by a
photoallegy to quinine
TROPICAL DOCTOR 2005; 35: 117–118

Case history
A 38-year-old woman, pregnant for 10 weeks (gravida 5,
para 5), was admitted to a rural inpatient clinic on the
western Thai–Myanmar border for uncomplicated Plas-
modium falciparum malaria. She was given supervised oral
quinine treatment at a dose of 30 mg/kg/day for six days.
She did not receive any other treatment.
After three days of quinine, she developed a pruritic
rash on the exposed areas of the face, trunk, arms and
legs. On examination she had a maculopapulovesicular
rash, mostly marked on the face (Figure 1, taken on day Figure 2 Photoallergic reaction to quinine showing a
4), with thick papulovesicular lesions and palpebral cheilitis on the lower lip

Tropical Doctor April 2005, 35 117

Downloaded from tdo.sagepub.com at Queen's University on October 19, 2014