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What is the underlying cause of recurrent liver abscess in the patient? Case data: The patient is a 46-year-old male with a history of recurrent liver abscess.
He went to the emergency department due to fever, chills, and malaise
.
The liquid culture of the previous abscess showed no bacterial growth, and the serological tests for endoamoeba histolytica, hydatid disease, toxoplasmosis, leptospirosis, human immunodeficiency virus and fungi were also negative
.
The patient has received multiple courses of long-term intravenous antibiotic therapy, and the last course of treatment was 1 year before this visit
.
Physical examination revealed: fever at 39.
5°C, mild sinus tachycardia, and multiple aphthous ulcers on the lower lip and gums, which are new symptoms of the patient
.
Preliminary laboratory examination results showed that the white blood cell count was 12.
9 g/dL, the hemoglobin and platelet counts were normal, and the C-reactive protein was 32 mg/dL
.
There was no obvious abnormality in the biochemical examination
.
Magnetic resonance imaging revealed 4 liver abscesses, up to 8 cm in size (Figures A and B)
.
The patient underwent liver drainage, and the aspirate culture was negative, mainly neutrophils
.
The patient was subsequently treated with broad-spectrum antibiotics
.
The patient then showed a history of chronic low back stiffness
.
Pelvic X-ray results are shown in FIG C
.
In addition, dermatological records showed that the patient had a history of painful penile lesions, manifested as purulent ulcers with purple-red edges destroyed
.
Despite the addition of antifungal drugs, the patient continued to have fever until a dose of dexamethasone was used to treat refractory nausea, at which time the patient's fever subsided
.
Which of the following diagnostic tests is most likely to confirm the underlying disease of the patient? A.
Liver biopsy B.
γ- interferon release assay C.
D.
penis lesion biopsy colonoscopy and biopsy analysis and diagnosis correct answer is D
.
Liver biopsy can be used to diagnose the cause of the biliary tract, such as primary biliary cholangitis, but magnetic resonance cholangiopancreatography is the preferred method for diagnosing the disease, and this method should be given priority before considering biopsy
.
The γ-interferon release test can be used to diagnose Mycobacterium tuberculosis infection, but the use of corticosteroids in tuberculosis patients may cause disseminated infections, rather than the fever subsided in this patient
.
Biopsy of penile lesions can help distinguish pyoderma gangrenosum from Behcet's syndrome
.
Although the patient had genital lesions, it did not meet the diagnostic criteria for Behçet’s syndrome in other aspects: a history of recurrent oral ulcers and ≥2 secondary features (including genital ulcers, eye lesions, and skin lesions)
.
In addition, sacroiliitis (Figure C) has nothing to do with Behcet's syndrome
.
The patient has aseptic liver abscess, oral ulcers, pyoderma gangrenosum, and sacroiliitis, and is suspected of potential inflammatory bowel disease (IBD)
.
Colonoscopy was performed on the patient, and the results showed a rectal ulcer (Figure D) and 2 anal fistulas
.
The biopsy confirmed chronic and acute inflammation and abscesses (Figures E and F)
.
The patient was diagnosed with Crohn's disease
.
Recognizing aseptic liver abscess Aseptic abscess (AA) is a rare extraintestinal manifestation of IBD, with fewer than 50 cases reported in the literature
.
The characteristic manifestations of AA include: ①abscess with aspiration dominated by neutrophils; ②negative bacterial and fungal culture; ③ineffective antibiotic treatment; ④corticosteroid therapy can quickly improve symptoms
.
Although AA is rare, this case suggests that IBD should be considered for patients with recurrent AA who have failed drainage and antibiotic therapy
.
References: Sheehan JL, Brandler J, Rice MD.
A Case of Recurrent Hepatic Abscesses[J].
Gastroenterology.
2021 Apr 8:S0016-5085(21)00627-2.
doi: 10.
1053/j.
gastro.
2021.
04.
007.
Contribution email: tougao@medlive.
cn