Respiratory Symptoms are the First Presentation of Liver Abscess

To the Editors: Liver abscess (LA) is uncommon in pediatric patients, accounting for 10–25 cases per 100,000 admissions.1 Most LAs are pyogenic, with Streptococcus spp. and Escherichia coli being frequent causes.2 While treatment advances have reduced mortality, long-term hospitalization remains a requirement. A 13-year-old boy with no remarkable medical history was referred to our department with a fever and persistent cough. His fever started 7 days before admission and he was initially prescribed clarithromycin. In 2 days, this was changed by the local physician to minocycline for the occurrence of a dry cough. His symptoms were exacerbated, and he was referred to our hospital. The patient was alert but exhausted. No oral trauma or dental cavity was detected. Chest auscultation was clear, and heart sounds were normal. The abdomen was soft but the liver was palpable 5 cm below the costal margin, with tenderness. No exanthema or scars were observed. Laboratory tests showed leukocytosis, elevated aspartate aminotransferase, alanine aminotransferase, and C-reactive protein (CRP) levels to 13,800/μL, (neutrophil 79.9%), 63 U/L, 80 U/L, and 21.69 mg/dL, respectively. Chest computed tomography showed mild pleural effusion (Fig. 1A) with a low-density area in the upper liver. A contrast-enhanced computed tomography revealed a 10-cm, ring-enhanced, solitary multilocular mass in the S7–S8 region (Fig. 1B). Fluoroscopy-guided puncture flowed 115 mL of pus, starting continuous drainage (Fig. 1C). Gram staining of pus revealed chained gram-positive cocci (Fig. 1D). The patient was diagnosed with pyogenic LA and administered ampicillin/sulbactam.FIGURE 1.: A: Chest computed tomography images showed no abnormal findings except for pleural effusion (arrowheads). B: Abdominal contrast-enhanced computed tomography revealed a 10 cm-sized, ring-enhanced, solitary multilocular mass in the S7–S8 region of the liver (arrow). C: 115 mL of milky pus was drained from the liver abscess. D: Gram stain of the pus showed gram-positive cocci in chains.Pus culture was positive for Streptococcus intermedius, whereas blood culture was negative. Confirming the decline in abscess size and CRP levels, drainage was removed. Pleural effusion initially increased, peaking around day 10, and the patient became afebrile. On day 26, the abscess size and the CRP level decreased to 4 cm and 1.85 mg/dL, respectively, with the dissolution of the pleural effusion. Oral antibiotics were prescribed, and the patient was discharged on day 27 (Figure, Supplemental Digital Content 1, https://links.lww.com/INF/F292). Outpatient follow-up showed continuous improvement, with the CRP level turning negative and the abscess shrinking to 2 cm in 3 months. With no signs of exacerbation, antibiotics were discontinued. The complete disappearance of the LA was confirmed at 9 months postadmission. Considering the rarity of large abscesses in children, he was screened for chronic granulomatous disease but was negative (Figure, Supplemental Digital Content 2, https://links.lww.com/INF/F293). Pediatric pyogenic LA often presents with fever and gastric symptoms. Respiratory symptoms, as seen in this case, are uncommon, and reported in 20%–30% of the patients.3,4 The mechanisms underlying respiratory symptoms remain unclear, with possible explanations being the spread of cytokine-mediated inflammation or physical obstruction. Streptococcus intermedius, an oral flora, was identified as the pathogen, suggesting hematogenous spread as the likely infection route. The impact of oral antibiotics could explain the negative blood culture. The low sensitivity of blood culture is also indicated in previous reports.1,4 Although severe LAs are known to be associated with chronic granulomatous disease,5 this patient showed no signs of inborn errors of immunity. In conclusion, LA should be considered as a possible differential diagnosis in patients with prolonged fever and respiratory symptoms.