Klebsiella pneumoniae liver abscess in an immunocompetent child
A 12-year-old boy was admitted to the Department of Pediatrics, Kangbuk Samsung Hospital, with a 4-day history of fever and headache. The day before admission, he vomited several times. On review of systems, the patient noted fatigue, headache, nausea, and vomiting, but denied any other symptoms, such as abdominal pain, diarrhea or visual change. He has been healthy without admission history or frequent infections. Family history was not remarkable. He did not have history of traveling, tick bites, or sick contacts during the last 6 months. His height was 158 cm (50th to 75th percentile) and weight was 45 kg (50th to 75th percentile). His initial vital signs included a temperature of 39℃, a heart rate of 126 beats/min, blood pressure of 118/74 mmHg, and respiratory rate of 20 breaths/min. He was alert. The scleras were not icteric and the neck was supple. The lungs were clear bilaterally, with no audible murmur on cardiac auscultation. The abdomen was soft and nontender, with no hepatosplenomegaly. The neurologic examination was unremarkable. The complete blood cell counts on the day of admission were hemoglobin (Hb), 12.0 g/dL; hematocrit (Hct), 35.1%; platelet, 179,000/mm3; and white blood cell (WBC), 15,400/mm3 (neutrophil, 85%; lymphocyte, 4%; monocyte, 11%). The blood chemistry showed glucose, 95 mg/dL (reference range, 60 to 100 mg/dL); aspartate aminotransferase (AST), 113 IU/L (reference range, 15 to 40 IU/L); alanine aminotransferase (ALT), 94 IU/L (reference range, 5 to 45 IU/L); lactate dehydrogenase, 605 IU/L (reference range, 120 to 330 IU/L); total bilirubin, 1.18 mg/dL (reference range, 0.2 to 1.3 mg/dL); total protein, 7.1 g/dL (reference range, 6.4 to 8.1 g/dL); albumin, 3.8 g/dL (reference range, 4.0 to 5.3 g/dL); alkaline phosphatase, 142 IU/L (reference range, 116 to 483 IU/L); γ-Glutamyl transpeptidase, 21 U/L (reference range, 25 to 24 U/L); and C-reactive protein (CRP), 22.05 mg/dL (reference range, <0.18 mg/dL). Coagulation panel demonstrated an international normalized ratio of 1.10 (reference rage, 0.89 to 1.10), prothrombin time of 12 seconds (reference range, 10 to 12 seconds), and activated partial thromboplastin time of 27 seconds (reference range, 26 to 37 seconds). The patient was negative for hepatitis B surface antigen and antibodies to hepatitis A and C virus. Abnormal findings were not observed in either the cerebrospinal fluid (CSF) study or the urinalysis test. Cultures of blood, urine and CSF were negative. The initial chest and abdomen X-ray had no remarkable findings.\nFive hours after the admission, he complained of right upper quadrant abdominal pain abruptly. Right upper quadrant tenderness was noted, but rebound tenderness was not. Due to abnormalities of liver function tests and abdominal pain, emerency abdominal computed tomography (CT) scan was ordered; it demonstrated 7.6 cm×9 cm×7 cm sized ill-defined multiply septated low density lesions in segments VII and VIII of the liver, consistent with hepatic abscess (). Hepatoduodenal ligament and lymph nodes were enlarged and these findings were regarded as reactive hyperplasia associated with the hepatic abscess. There were no remarkable findings in the gastrointestinal tract including appendix and other solid organ. Venous thrombosis was not seen in abdominal CT. The portal vein, hepatic vein and its branch were patent. The patient was treated empirically with parenteral antibiotics (metronidazole, 30 mg/kg/day; ceftriaxone, 100 mg/kg/day; amikacin, 22.5 mg/kg/day) and underwent ultrasound-guided percutaneous catheter drainage (PCD) of the liver abscess. Eight-French multiple-sidehole pigtail catheter were inserted into the abscess cavity and about 30 mL of thick dark-yellowish pus was drained. The procedure was performed under local anesthesia with the patient in supine position. Conscious sedation was not used. Drainage of the abscess yielded purulent material that grew K. pneumonia sensitive to all tested antibiotics, except for ampicillin and piperacillin. Amoeba antibody was negative. To evaluate the immune status of the patient, serum immunoglobulins (Ig), complements (C), and lymphocyte subsets were measured and the dihydrorhodamine (DHR) test was performed. Serum IgG (1,180 mg/dL), IgA (331.1 mg/dL), IgM (72.5 mg/dL), C3 (86.2 mg/dL), C4 (14.89 mg/dL), total complement activity (CH50 47.7 U/mL), and lymphocyte subsets, including CD3 positive T-cells (87%, 2,514/µL), CD4 positive T-cells (T4, 44%, 1,271/µL), CD8 positive T-cells (T8, 31%, 896/µL), T4/T8 ratio (1.42), CD19 positive B-cells (7%, 202/µL), and CD3 negative and CD16 and CD56 positive natural killer cells (6%, 173/µL), were all in the normal range for his age. No abnormal findings were observed in the DHR test.\nOn hospital day 11, the fever subsided. Also his headache, and right upper quadrant abdominal pain were improved. The laboratory findings were Hb, 11.8 g/dL; Hct, 34.8%; WBC, 10,600/mm3 (lymphocyte, 27%; neutrophil, 64%; monocyte, 7%; eosinophil, 2%); platelet, 495,000/mm3; CRP, 3.81 mg/dL; AST, 24 IU/L; and ALT, 8 IU/L. On hospital day 12, a follow-up abdominal CT scan revealed a slightly decreased, but residual hepatic abscess (5.9 cm×6.1 cm×5.5 cm) in the right lobe and bilateral pleural effusion with passive atelectasis. Pus (40 to 120 mL daily) was drained initially, but the rate of drainage gradually decreased to less than 10 mL per day over 3 weeks and drainage material became serous. On hospital day 20, a right upper quadrant ultrasound showed that the size of the liquefied abscess cavity had reduced to 3 cm. The percutaneous catheter was removed on hospital day 21 because the amount of drainage was scanty. The total amount of pus drained from abscess cavity was 370 mL for 20 days. On hospital day 25, subsequent ultrasound demonstrated a significant reduction in size of the abscess. Laboratory findings on hospital day 28 were improved as follows: WBC, 5,900/mm3 (neutrophil 48.9%); CRP, below 0.5 mg/dL; AST, 34 IU/L; and ALT, 10 IU/L. The patient was discharged on hospital day 29 and was switched to oral forms of treatment. The oral antibiotic, cefixime, was administered for 14 days. Two weeks after discharge, the third follow-up abdominal CT scan was performed in an outpatient setting: it revealed that the abscess of the right lobe was almost healed and the bilateral pleural effusions with passive atelectasis were disappeared (). The patient is now under follow-up care and has remained well over the last five months.