Case 167

By:Abdelwahab Elsadany

MD Pediatrics PhD ped study children special

need

دكتورعبد الوهاب محمد

السعدني الزقازيق طب ـ أطفال طب دكتوراه

الخاصة االحتياجات ذوى وتغذيه دكتوراه صحة

األطفال شمس عين طب ـ الحميات أمراض وعالج تشخيص في الدكتوراه

Name ……: Age; 65 yearsSex: femaleResidence: meat AliOccupation :house wifeMariatal state married

Social state HighDiabetic 20 years ago hypertensive 15 years ag

Personal history

Complaint

Fever for 3 months not responding to treatment

Headache , anorexia …easily tired sweating and occ

palpitationSense of abdominal discomfort and

fullness.………………

Present historyStarted 3 months ago by sudden onset of febrile illness with generalized boneache , headache, sweeting easily tired sense of abdominal fulness indigestion and anorexia

Fever increased at night with shivering sweating and shortness of breath with palpitation

diagnosed as Enterica

Patien asked many Med advices and all shared diagnosis of Typhoid fever

Treated 10 days with Ciprofloxacin twice daily with minimal improvement

Of some Symptoms

Patint reevaluated

Pyogenic sinsuits by ENT consultant based on xRay nasal sinuses

Received home medication Augmentin Two weeks

Minimal improvement of fever and headache

Patient by lab and positive lab for Malta fever Given treatment for brucellosis for 8 weeks with no response Asked medical advice by fever specialist

Refered to hospital with the above symptoms

No response

Through history and repeated physical examination revealed

General examinationAlert,conscious,active ,non toxicT 39 c

RR 22/mِHR 92/m

,B P 145/95Chest: BEAE

CVS: S1-S2-OGIT: soft no visceromegaly

CNS: NADL L minimal pertibial edema

LAB Results

CBC: TLC:9.6 RBCs: 3.64 HB: 10 PLAT: 296 ESR: 110 ASO: -VE CPR: 12 FU SUGAR :404

URINE ANALYSIS PUS: 5-7

GLUCOSE++ PROTEIN++ :

Widal 1l160 H:-ve

Brucella:-ve S.creatinine: 1

Liver enzymes: normalzٌKideny Function Normal

RADIOLOGICAL STUDY

CXRABD U S

ABDOMINIAL COPUTARIZED CTABD MRI

Chest x ray : freeAbdominal U/SMultiple focal lesions for C/T liver

CT ABDOMEN:Mildly enlarged liver with multiple variable sized marginally enhanced cystic lesions are seen scattered in both liver lobes and caudate lobe . the largest measures about 3.5 cm in diameter and located in medial segment of the left liver lobe…… signs cobe with multiple liver granulomas Normal enhancement of the main portal vein and its two main branches. No dilated intra-hepatic biliary rdicals

19-3-2012Refered for guided CT liver

aspiration and drainage for Histopathology and

microbiological study

BIOPSY under guide CT

Slowly growing gram +ve bacteria

:actinomyces israeli

LIVER BIOPSY

Monday 23-4-2012Resolution of all hepatic absceses

and largest one resoled with half cm in diameter

Pateient will continue ttt at hospital for further two weeks

under tttt by.…………………………………………………

Abstract

Femal ward 65ys diabetic hypertensive hepatic actinomycosis Acombination of surgrgical radiological dranage and antibiotic proved to lead to complet cure

للجميع شكرا

discussionActinomycosis liver abscess is comonly assoc with

nonspecific clinical and lab signs of infection

Immagine usualy review aspace occuping lesion suggest either hepatic

tumor or pseeudotumor or inflamatory Adefinitive diagnosis is histopathology tests on

sample obtained under screen

Adefinitive diagnosis is histopathology tests on sample obtained under screen

Felekouras et al (92) report hepatic lobectomy in ؛

Felekouras et al (92) report hepatic lobectomy in ؛

case of isolated hepatic actinomycosis(case report)

Ped R health sci J 11:19-21؛

Samuel 1999 Post g Med j liver acinomycosis as C/o diverticulosis

liver acinomycosis as liver mass by Vargas 92 medicine 21 111-115

0ٍsugano etal in Japan hapatic actinomycosis in japan case report J gastroentro 9732;;672;6

Ali et al 97 hepatic inv in diss actinomycosis Panc sur 3 ;337;9

Bown etal 2011 report acase presenting solely as hapatic mass co actinomycosis

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Actinomycosis

ActinomycesSlow growing gram +ve bacteria , it is a part of the oral flora in humans, flamentous structure gives them fungal like appearance

discussioncase of isolated hepatic actinomycosis(case report)

Ped R health sci J 11:19-21؛

Samuel 1999 Post g Med j liver acinomycosis as C/o diverticulosis

liver acinomycosis as liver mass by Vargas 92

medicine 21 111-115

Actinomycosis

IActinomycosis is infection is infection caused by actinomyces bacteriaCharacterized by characteristic granulomatous suppurative disease characterized by peripheral spread with formation of draining sinus affect cervicofacial,thoracic,abdominal,pelvic

Actinomyces in clinical specimen sputum .crust purulent exudate surgical nacropsy ,rinsed stain reveal organisms with classic silver granules

c/sbrain,heart infection agar 37 c 95% nitrogen 5 % co2 incubate aenerobically organism within 24h israile filaments spiderlike growth

epidemiology worldwide without relation to age ,sex,race,season or occupation review 85% case youngest one 28day etiology human flora increased in patient with steroid leukemia renal cong imm def.HIV

pathogenesischronic suppurartive scaring inflammatory process with dense cellular infiltrate with suppuration forming many connecting abscess with sinus tractssite involves,lung.abdomen,orofacial

c/p of abdominal and pelvicafter disruption of mucosa of GIT hepatic affection 15% as solitary or multiple liver abscesseschillsfevernight sweetsweight losssimilar to TB

diagnosismicroscopic examination with appropriate stainc/s of purulent discharge actinomyces irregular non spore forming non acid fast non moblle gram +ve bacillusc/s aerobic non aerobic

abdominal CTa contrast enhancing multicystic lesions that can be approached by CT guided needle biopsy and C/S 

Treatmentprolonged antibiotic therapy and drainaagePenicillin 250mg/kg/24h q4hTetracycilin clendimycin chloramephenicol injection 2-6 weeksOral3-12 months

THANK YOUBy:Abdelwahab Elsadany