Isolated Tubercular Liver Abscess In Pediatric Age Group

Amit Chaudhary; Ashish Wakhlu

摘要

We report about two patients, the first 7 years and the second 10 years old presenting in our outpatient clinic with history of pain in right upper abdomen, high fever, anorexia and weight loss. A detailed search failed to identify any other focus of tubercular infection. Laparotomy was carried out in the first patient as the abscess was multiloculated and inaccessible to percutaneous aspiration. Antitubercular therapy was begun in the postoperative period when high fever persisted and polymerase chain reaction came out positive for Mycobacterium Tuberculosis. In the second patient diagnosis was made by enzyme linked immunosorbant assay but surgical drainage was done because percutaneous aspiration failed to drain the multiloculated abscess. Both the patients showed dramatic response with antitubercular therapy and gradually hepatomegaly regressed. Isolated hepatic tubercular liver abscess, though a very rare diagnosis should always be considered when signs and symptoms fail to improve with antiamoebic, antibacterial therapy and conventional surgical management. Introduction Isolated tubercular abscess of liver is very uncommon in pediatric age group. We present 2 patients aged 7 years and 10 years respectively, presenting with isolated tubercular liver abscess. In the first patient the clinical and peroperative diagnosis was pyogenic abscess but the condition kept deteriorating after surgery and broad spectrum anti-bacterial coverage. Polymerase chain reaction (PCR) and enzyme linked immunosorbant assay (ELISA) came out to be positive for Mycobacterium Tuberculosis. Antitubercular therapy (ATT) was started, which showed dramatic response. In the second patient preoperative diagnosis was established by ELISA and ATT was started Both patients were followed for 1 year and are alive and well. Case Report Two patients were admitted in the department of pediatric surgery between Jan 2002 to Mar 2003 with complaint of pain in right upper abdomen, high grade fever, anorexia and weight loss for 3 months and 2 months respectively. Clinical examination revealed tender hepatomegaly and the intercostals spaces overlying liver were tender in both. There was no jaundice, both children were anaemic (hemoglobin 7gm% and 8gm% respectively) and showed lymphocytosis. Erythrocyte sedimentation rate was elevated in 1st hour (Westergren method). The liver function tests were within normal limits and Montoux test was positive in both the patients. Screening for HIV and HBsAg was negative. Chest X-ray showed elevation of the right dome of diaphragm in both and basal infiltrates in one patient. There was no evidence of pulmonary tuberculosis on chest X-ray. Ultrasound and CT scan of the abdomen were done in both the patients. In first child (7 years old) the abscess was located in the posterosuperior aspect of right lobe and was multiloculated. The abscess being very close to inferior vena cava was not amenable to percutaneous aspiration. Laparotomy was performed and a large multiseptate abscess having very thick fibrous wall was identified. About 350ml of thick white pus was removed after breaking the loculi. Abdomen was closed after putting a wide bore drain in the abscess cavity. The diagnosis of pyogenic liver abscess was made peroperatively and the patient was put on broad spectrum intravenous antibiotics (cephalosporin, aminogylcoside and metronidazole). This child showed no signs of improvement and from 2nd postoperative day started running high fever. In addition he developed right sided pleural effusion with respiratory distress and required transfer to pediatric ICU. During investigation in ICU, ELISA and PCR were performed and both came out positive for Mycobacterium Tuberculosis. ATT was started and the child showed dramatic response. The child was discharged from hospital on four drug ATT (Rifampicin, Isoniazid, Ethambutol and Pyrazinamide) continued for total of 8 weeks. At four weeks follow up he was asymptomatic and the hepatomegaly ha

机译：我们报告了两名患者，前7岁和后10岁在我们的门诊就诊，有右上腹疼痛，高烧，厌食和体重减轻的病史。详细的搜索未能发现结核感染的任何其他焦点。由于脓肿位于多处且无法经皮穿刺抽吸，因此在第一例患者中进行了剖腹手术。术后持续高烧，聚合酶链反应呈阳性的结核分枝杆菌阳性后开始抗结核治疗。在第二例患者中，通过酶联免疫吸附测定进行了诊断，但由于经皮穿刺术无法引流多处脓肿而进行了引流。两名患者在抗结核治疗中均显示出显着的反应，并逐渐肝肿大消退。孤立的肝结核性肝脓肿，尽管在使用抗贫血，抗菌治疗和常规手术治疗未能改善体征和症状时，应始终考虑非常罕见的诊断。引言在小儿年龄段，孤立的肝结核脓肿很少见。我们目前有2例分别为7岁和10岁的患者，均患有孤立性结核性肝脓肿。在第一例患者中，临床和围手术期诊断为化脓性脓肿，但术后和广谱抗菌覆盖范围持续恶化。聚合酶链反应（PCR）和酶联免疫吸附测定（ELISA）对结核分枝杆菌呈阳性。开始了抗结核治疗（ATT），反应显着。在第二例患者中，通过ELISA建立了术前诊断并开始了ATT治疗。两名患者均被随访了1年，并且还活得很好。病例报告2002年1月至2003年3月，小儿外科收治了2例患者，主诉右上腹部疼痛，高烧，厌食和体重减轻，分别为3个月和2个月。临床检查显示，肝肿大且肝脏上方的肋间隙较软。没有黄疸，两个孩子都贫血（血红蛋白分别为7gm％和8gm％）并表现出淋巴细胞增多。第1小时，红细胞沉降率升高（Westergren法）。两名患者的肝功能检查均在正常范围内，Montoux测试为阳性。 HIV和HBsAg筛查阴性。胸部X线检查显示一名患者的diaphragm肌右穹do升高和基底浸润。 X线胸片无肺结核的证据。两名患者均进行了腹部超声和CT扫描。在第一个孩子（7岁）中，脓肿位于右叶的后上位，并位于多处。脓肿非常接近下腔静脉，不适合经皮穿刺。进行了剖腹手术，并发现了一个巨大的多隔膜脓肿，纤维壁非常厚。破损后除去约350ml浓稠的白色脓液。在脓肿腔中放宽口径的引流管后，关闭腹部。术前诊断为化脓性肝脓肿，并给患者服用广谱静脉注射抗生素（头孢菌素，氨基糖苷和甲硝唑）。这个孩子没有任何改善的迹象，并且从术后第二天开始发高烧。此外，他发生了右侧胸膜积液并伴有呼吸窘迫，需要转移至小儿ICU。在ICU进行调查期间，进行了ELISA和PCR检验，均对结核分枝杆菌呈阳性。 ATT开始了，孩子表现出戏剧性的反应。该患儿因服用四种药物ATT（利福平，异烟肼，乙胺丁醇和吡嗪酰胺）出院，总共持续了8周。在四个星期的随访中，他没有症状，肝肿大

Isolated Tubercular Liver Abscess In Pediatric Age Group

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