A rare case report on neonatal complications from Nepal: solitary neonatal hepatic abscess

Introduction and Importance:

Neonatal liver abscess is a rare condition with a high mortality rate. However, in a low-resource setting, high clinical vigilance and the use of readily accessible diagnostic modalities can help in early diagnosis and, along with appropriate medical management, prevent lethal complication.

Case presentation:

We present the case of a patient who presented with one day of sudden abdominal distension and two episodes of projectile nonbilious vomiting. A solitary liver abscess was diagnosed using ultrasonography and contrast-enhanced computed tomography findings, and the patient was treated conservatively with parenteral broad-spectrum antibiotics. Following the completion of the antibiotic dose, an ultrasound of the abdomen reveals that the size of the liver abscess has decreased.

Clinical discussion:

Neonatal liver abscess is a rare clinical condition that causes significant morbidity and mortality in premature and term babies. In a neonate with potential risk factors, a high index of suspicion is required to make the diagnosis. Baseline tests, as well as computed tomography with or without contrast, aid in the definitive diagnosis of a hepatic abscess. For management, a multidisciplinary approach should be considered, including correction of the predisposing factor as well as appropriate medical and/or surgical intervention.

Conclusion:

Neonatal liver abscess is frequently overlooked due to its rarity. Thus, whenever a neonate exhibits the aforementioned clinical spectrum, it should be considered in the differential diagnosis, and a diagnostic workup and treatment should be initiated as soon as possible to avoid debilitating complications.

Introduction

Highlights

• Neonatal liver abscess is a rare clinical condition.

• It leads to significant morbidity and mortality in preterm and term neonates in the absence of an early diagnosis.

• High vigilance, early diagnostic workup, and appropriate medical treatment minimize the potential complication.

Neonatal liver abscess is a rare clinical entity that can affect both term and preterm babies and is still associated with high mortality rates of up to 50% among preterm neonates in developing countries, despite proper care and treatment1,2. It can be idiopathic or secondary to risk factors such as umbilical vein catheterization, systemic sepsis, necrotizing enterocolitis, prematurity, low birth weight, prior abdominal surgery, and underlying immunodeficiency3–5.

Ultrasonography (USG) and computed tomography (CT) with intravenous (i.v.) contrast, as well as a high index of suspicion, aid in the diagnosis of the condition1,5. Treatment strategies include correction of the predisposing factors, drainage of the abscess, or appropriate parenteral antibiotic therapy1.

To date, very few cases have been reported in the literature, and no such case appears to have been reported from Nepal. We present the case of a term neonate who presented with vomiting but no signs of sepsis or other risk factors, was diagnosed with a solitary hepatic abscess, and was treated conservatively without invasive procedures.

Methods

This case is reported in accordance with the Surgical CAse REport (SCARE) guidelines6.

Case presentation

A 28-day-old, normally breastfed male neonate was brought to our center’s emergency room by his parents with a complaint of one day of sudden abdominal distension and two episodes of projectile, nonbilious vomiting. There is no history of fever, yellowish discoloration of the body, changes in the color or frequency of stools, difficulty urinating, irritability, photophobia, rashes, abnormal limb movement, or breathing difficulty. According to his parents, he was born of non-consanguineous parents via the normal vaginal route at a central hospital with a birth weight of 2900 g and no subsequent fetal complications. Furthermore, she denied any history of trimester-wise complications. Similarly, he has completed his immunizations in accordance with Nepal’s extended immunization program to date. There is no significant family, personal, past history, or allergic history associated with his present conditions.

On clinical examination, his vital parameters are normal for his age. There is no pallor, icterus, lymphadenopathy, cyanosis, edema, or any other signs of dehydration. A head-to-toe examination revealed no gross abnormalities. The abdomen was distended, with tenderness in the right hypochondriac region, but the umbilicus was normally aligned, with no distension of the superficial vein and no local rise in temperature or change in bowel sounds. Other systemic examinations, however, revealed no significant abnormal findings.

He was then admitted, and a baseline investigation was conducted. Except for erythrocyte sedimentation rate (ESR) (25 mm in the first hour) and a positive C-reactive protein (CRP), laboratory analysis revealed normal values for all parameters (red blood cell count, white blood cell count, platelets, hemoglobin, random blood sugar, renal, and liver function tests). Hepatitis and HIV I and II viral markers were negative. Similarly, the blood culture was sterile, as were the equivocal amoebic serology results (IgG-0.92). An ultrasound of the abdomen and pelvis was also ordered, which revealed borderline hepatomegaly with a hyperechoic area noted in the left lobe of the liver measuring 22×19 mm and minimal vascularity noted peripherally with a differential diagnosis of liver abscess and recommendation for contrast-enhanced computerized tomography abdomen and pelvis, which revealed an enhancing thick-walled multiloculated cystic space-occupying lesion measuring 35×24 mm is seen in the left lobe of the liver (segment IVa/b) without any areas of calcification (Fig. 1). Similarly, alpha-fetoprotein levels were ordered to rule out hepatoblastoma and hepatic hamartoma, both of which were negative.

Figure 1.

Enhancing thick-walled multiloculated cystic space-occupying lesion measuring 35×24×22 mm is seen in the left liver lobe (segment IVa/b) with non-enhancing area within. SOL, space-occupying lesion.

Based on the clinical presentation and diagnostic workup, a provisional diagnosis of the neonatal hepatic abscess was made. Following that, the baby was planned to be managed conservatively with broad-spectrum i.v. antibiotics (metronidazole 30 mg three times a day along with flucloxacillin 75 mg four times a day for 14 days) along with breastfeeding without drainage of the abscess and was discharged on oral antibiotics for another 28 days. A follow-up USG of the abdomen after completion of the antibiotic dose revealed that the liver abscess had resolved, with no resolution of the liver abscess with no further complications.

Clinical discussion

Neonatal liver abscess is a rare clinical condition that causes significant morbidity and mortality in preterm and term neonates3. Among the various components, umbilical catheterization, low birth weight, and prematurity remain the commonest predisposing factors, as well as birth asphyxia, exchange transfusion, necrotizing enterocolitis, antecedent abdominal surgery, omphalitis, immunodeficiency, and total parenteral nutrition via the umbilical cord, which remains the least common factor4,7. However, our patient was a term neonate without any significant predisposing factors.

Although any organisms can be accountable for the disease in this age group, the most common causative organisms are Staphylococcus aureus, Streptococcus pyogenes, and Escherichia coli. Polymicrobial infections can also be seen in 50% of the cases1,7. Pathogenesis occurs primarily through three mechanisms: pathogens ascending through the portal vein to the liver; hematogenous spread via the biliary tree or hepatic artery; and direct invasion from surrounding structures4,8.

Early hepatic abscess presents with nonspecific signs and symptoms, which include fever, right upper quadrant pain, intolerance to feeding, vomiting, abdominal tenderness, abdominal distension, etc1,9. In our case, the patient presented with abdominal distension and vomiting.

It is essential to raise a high index of suspicion in a neonate with potential risk factors to establish the diagnosis. Because of its low cost, noninvasive nature, mobility, and accessibility, abdominal ultrasound is the initial and preferred investigation for detecting abscesses2. Ultrasound scanning established the diagnosis in our patient by showing a hyperechoic area noted in the left lobe of the liver. The firm diagnosis is provided by abdominal CT with or without contrast, which shows a well-circumscribed, low-attenuation mass with a contrast-enhancing rim. The raised diaphragm can be noted in a plain radiograph of the abdomen2,7,8. In addition to this, leukocytosis, neutropenia, thrombocytopenia, an increased ESR, and elevated or normal liver enzymes are nonspecific laboratory findings1. On the contrary, our patient only has an increased level of ESR with a positive CRP status. Similarly, hepatoblastoma and hepatic hamartoma are differential diagnoses that must be ruled out and can be done with alpha-fetoprotein, which was unremarkable in our case8.

Neonate liver abscesses are typically multiple, small, and non-drainable, with an acute fulminant course, generalized sepsis, and multiple abscesses in other organs3,10. Studies have shown that only 30% of the total number of liver abscesses are solitary10. The neonatal liver abscess is best managed with medical therapy with or without abscess drainage depending upon the status of the abscess, that is pyogenic or non-pyogenic2,8,10. A multidisciplinary approach should be considered for the management, which includes correction of predisposing factors (e.g. withdrawal of the umbilical catheter), percutaneous drainage of the abscess with or without the guidance of USG, or open drainage for large abscesses and abscesses affecting multiple lobes. Image-guided aspiration of the abscess showed a good prognosis1,2,7.

Open surgical drainage of the abscess with i.v. antibiotics is the traditional approach for solitary hepatic abscesses3. Solitary liver abscesses are well-localized, large, and easily drainable by surgical methods2,3. Infections that are culture-positive should be treated with parenteral antibiotic therapy as the mainstay of treatment in compliance with culture and sensitivity; however, infections that are culture-negative should be treated with broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic organisms2,8. Due to the sterility of the culture of our patient, despite the solitary nature of the hepatic lesion, our patient was considered for medical management. Treatment with antibiotics should continue for at least 3–6 weeks3,8. In our case, the patient received parenteral broad-spectrum antibiotics for 2 weeks and oral antibiotics for 4 weeks.

Delay in treatment provides an invitation to deleterious complications such as portal vein thrombosis, portal cavernoma formation, and portal hypertension, so early either medical or surgical drainage is of high essence in the management of neonatal hepatic abscess2,7,8.

Conclusion

Neonatal liver abscess is frequently overlooked due to its rarity in developing countries like Nepal. Therefore, if a neonate exhibits the aforementioned signs and symptoms, the treating professional should be cognizant that a hepatic abscess could be held responsible. As a result, prompt diagnosis and treatment can be performed, thus preventing debilitating complications.

Ethical approval

There were no animal or human experiments in this study. The patient’s parents permitted the publication of his information in this case report.

Consent

Written informed consent was obtained from the patient’s parents for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Patient perspective

The patient expressed her gratitude for the diagnosis and treatment of her illness.

Sources of funding

All authors declare that this research did not receive any specific grant or funding from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

B.R.Y. and B.M.B.: involved in patient care (diagnosis, treatment, and follow-up) and revision of the manuscript; S.T. and S.B.: contributed to the collection of case information, writing of the manuscript, manuscript revision, and submission of the manuscript. All authors approved the final version.

Conflicts of interest disclosure

All the authors declare that they have no conflicts of interest.

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Bal Mukunda Basnet.

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Not commissioned, externally peer-reviewed.