Case Discussion      A 58-year-old woman was admitted because of intermittent high fever with chills for 5 days.      She was a housewife without any known systemic diseases, such as hypertension, diabetes, liver or renal diseases. She did not have the habit of smoking or drinking and no travel history recently. Polydipsia and polyuria developed since 2 months ago. Fever associated with chills, general malaise and abdominal fullness were noticed since 5 days ago. Her body temperature had been elevated up to 39.6° C. No severe abdominal pain, cough, dysuria or diarrhea was complained. Although high fever could subside after medical treatment from outside clinic, but it recurred several hours later. So she came to ER for help.      At ER, her consciousness was clear and oriented. The temperature was 38° C, pulse rate 123/min, respiratory rate 24/min and blood pressure 100/62 mmHg. The conjunctivae were not pale or injected and sclera was anicteric. Pupils were isocoric and throat was not injected. The neck was supple without lymphadenopathy. The jugular veins were not distended. Respiratory sounds were symmetric and clear. Rapid heart beat without audible murmurs were observed. Abdomen was soft, but mildly distended. Liver margin was palpable at 2 cm below the right costal margin. No tenderness was detected. Bowel sounds were normoactive. There was knocking pain at the right flank. The extremities were freely movable without pitting edema or ecchymosis. Laboratory Data: 1. CBC and differential count: WBC /μl RBC M/μl Hb g/dl Plt K/μl Hct % MCV fL Band % Neu % Baso % Eos % Mon % Lym % 9530 3.84 11.1 195 34.0 87.3 14 78 0 0 3 5 2. Biochemistry: A/G g/dl BilT/D mg/dl ALP U/L AST U/L ALT U/L r-GT U/L BUN mg/dl Cre mg/dl Na mM K mM Cl mM 2.4/3.5 1.5/1.0 495 22 30 335 18.6 1.1 134 3.4 102 Ca mM/dl P mg/dl Mg mM/dl Glu mg/dl LDH U/L TG mg/dl T-CHO mg/dl UA mg/dl 1.87 3.4 0.82 335 392 75 123 6.8 3. Urinalysis: Outlook PH Pro Sugar KB OB Bil Urobil RBC WBC Epi Y,C 5.0 - 3+ - 2+ 1+ 1.0 2-4 1-2 0-1 4. PT: 16.6/12.4 sec.; PTT: 56.2/39 sec. 5. Arterial blood gas: (O2 nasal cannula 3l/min) PH PaCO2 PaO2 BE HCO3 SaO2 7.438 26.3 92.0 -6.8 15.1 98.1% 6. Stool occult blood (-) 7. HbA1c: 12.6% 8. Blood culture: Klebsiella pneumoniae 9. IHA test: 1: 8 (-) 10. Abdominal sonography Course and Treatment:       Although no leukocytosis was seen, there was left shifting distribution of white blood cells. Empirical antibiotics with cefazolin 1gm IV q8h and gentamicin 160mg IV drip qd were prescribed for possible infection after blood culture. Insulin treatment was also started for poor-controlled hyperglycemia and she was admitted. Abdominal sonography revealed a hypoechoic lesion, measuring 6.8 x 5.9 cm, at right lateral superior segment of the liver. Liver abscess was impressed. On the third day after admission, fever still persisted and sudden onset of right eye pain with injected conjunctivae developed. Progressively blurred vision was told thereafter. Blood culture disclosed Klebsiella pneumoniae and septic endophthalmitis was favored for her visual loss. Antibiotic was shifted to ceftriaxone 2gm IV q12h. Ultrasound-guided drainage of liver abscess was performed and pus-like fluid was withdrawn. The fever was controlled later, but the visual acuity didn't improve much. Subconjunctival injection of ceftazidime and amikacin were done and vitrectomy was performed later. The antibiotic was continued for 4 weeks. Hyperglycemia was controlled by oral hypoglycemic agent. However her visual acuity was still poor with only capability of counting fingers at 15 cm distance. 病例分析         本病例為一位中年女性發燒及上腹部不適多日，經多次就醫後症狀仍未改善，經過胸部X光及尿液檢查排除常見的呼吸道及泌尿道感染，在進一步作腹部超音波檢查，後來診斷其本身有糖尿病，發生了肝膿瘍併有Klebsiella pneumoniae敗血症，期間更併發眼內炎，造成視力的不可逆的傷害。糖尿病的病人，若是血糖控制不良， 人體的白血球功能便受到影響，特別是吞噬殺菌的能力會降低，因此糖尿病的病人，較常見到細菌的感染，更有一些特殊的嚴重感染疾病好發在糖尿病病人身上，如Emphysematous pyelonephritis、Emphysematous cholecystitis、Malignant otitis externa、Rhinocerebral mucomycosis以及本例的Klebsiella pneumoniae liver abscess with endophthalmitis等，Klebsiella pneumoniae造成肝膿瘍，甚至進而演變成眼內炎的病例，在台灣地區比世界其他地區來得多，至今仍未有確切的解釋原因，因為致病的菌種並未發現有所不同，更可惜的是目前仍不能預測何種病人較易發生眼內炎，而及早實施眼內抗生素治療，以補強一般抗生素在眼球內的不足藥效，否則一旦症狀出現後病人的視力都會受到不可逆的傷害。         此外肝膿瘍的產生致病菌種多來自腸胃道、膽道的感染，另有少數是源自血行性感染、臨近器官的感染或是外傷穿透引起，菌種以腸內菌如E. coli、Klebsiella、Enterococcus、Anaerobic pathogen及Amoeba，隨著癌症及血液腫瘤作化學治療病人的增多，黴菌或是結核菌的肝膿瘍的病例也有增加的現象，另外也要注意是否化膿性肝膿瘍為續發自肝臟腫瘤。 繼續教育考題 1. (D) Which is the most common pathogen of pyogenic liver abscess complicated with endophthalmitis in Taiwan? A E. coli B Proteus C Enterococcus D Klebsiella pneumoniae 2. (B) Which is not the infection occurring principally in patients with diabetes? A Emphysematous cholecystitis B Tuberculosis menigitis C Pyogenic liver abscess D Malignant otitis externa 3. (C) Which is the less common infectious source contributing to liver abscess? A Cholecystitis B Cholangitis C Cellulitis of thigh D Colitis 4. (C) Which liver test is most frequently abnormal in patients with liver abscess? A Bilirubin B Aminotransferases C Alkaline phosphatase D Lactic dehydrogenase 5. (C) Which is the most effective antibiotic in the treatment of pyogenic liver abscess with septic endophthalmitis? A Cefazolin B Amikacin C Ceftriaxone D Erythomycin 6. (A) Which is the best choice of treatment for amoebic liver abscess? A Metronidazole B Aspiration C Pigtail drainage D Operation 7. (C) Which is the best test in the differential diagnosis of amebic liver abscess? A Negative amebic cysts in stool to exclude diagnosis B Elevated serum IHA to favor diagnosis C Normal serum IHA to exclude diagnosis D Negative past history of dysentery to exclude diagnosis 8. (B) Which patient is less susceptible to fungal liver abscess A Patient receiving chemotherapy B Diabetic patient C Patient with long- term steroid usage D HIV patient 9. (C) How long the antibiotic treatment for patients with drained pyogenic liver abscess is adequate? A 7 days B 10 days C 4weeks D 8 weeks 10. (B) Which is wrong in the following statements? A Half of patients with liver abscess have no symptoms or signs that would direct attention to the liver. B Drainage of amebic liver abscess would shorten the recovery period. C Fever is the most common presenting sign of liver abscess D Pyogenic liver abscess without drainage requires longer course of antibiotic treatment

答案解說 答案解說: 1. 台灣地區引起pyogenic liver abscess的菌種，Klebsiella pneumoniae就佔了50-70%，而引起endophthalmitis 合併症者幾乎都是這種細菌。 2, 3. 見病例分析文內說明。 4. Elevated serum concentration of alkaline phosphatase is documented in 90% of patients with liver abscess. (Harrison 14th ed, p795) 5. Third generation cephalosporin對於blood-retina barrier才有較佳的穿透性，並配合intravetreous antibiotic injection使用，才能對endophthalmitis作最佳的治療。 6. Metronidazole, 750 mg three times a day for 5-10 days, is the treatment of choice for amebic liver abscess. 7. Amebic serologic testing gives positive results in more than 95% of cases; thus negative result helps to exclude this diagnosis (Harrison 14th ed, p795). IHA may remain positive for some time after a clinical cure. A past history of amebic dysentery is rare. Only 15 % of patients can find amebic cysts in stool. 8. Fungal liver abscesses usually affect the immunocompromized patients. 9. Drained liver abscess is usually treated by antibiotic at least 4 weeks and the one without definitive drainage needs longer course. 10. Amebic liver abscess is usually resolved with medical treatment. Unnecessary percutaneous drainage may increase the risk of fistula formation and potential spread. Drainage is considered when abscess is near the critical organ (such as left lobe abscess near the pericardium) or for differentiation the possibility of associated pyogenic abscess.