1. GOOD MORNING!

2. MEDICAL GRANDROUNDS Antonio A. Carlos, Jr., MD First Year Resident 12 June 2008

3. THE GREAT IMITATOR

4. OBJECTIVES • To present a case of liver abscess with an unusual cause; • To give an overview on the etiology and management of liver abscess; • To discuss melioidosis, its diagnosis and management.

5. Santiago City, Isabela

6. Santiago City, Isabela

7. E. B. 58 year-old female Married Farmer Non-diabetic Non-hypertensive IDENTIFYING DATA

8. CHIEF COMPLAINT Abdominal pain

9. HISTORY OF PRESENT ILLNESS 8 months prior to admission, • crampy left upper quadrant abdominal pain • occur intermittently • no fever, vomiting, and diarrhea

10. consulted at a local hospital • abdominal ultrasound showed the presence of three hepatic nodules • no treatment was done due to financial constraints • lost to follow-up

11. 2 months prior to admission, • intermittent abdominal pain • consulted in another local hospital • abdominal CT scan showed the presence of five hepatic nodules • advised biopsy of the nodules • opted to seek second opinion

12. 2 weeks prior to admission, • consulted a gastroenterologist in Manila • EGD was done • showed gastric ulcer • biopsy of the ulcer showed positive for Helicobacter pylori • started on H. pylori regimen

13. advised admission for the work-up of the hepatic nodules

14. PAST MEDICAL HISTORY (-) Hypertension (-) Diabetes (-) Bronchial asthma (-) Tuberculosis

15. FAMILY MEDICAL HISTORY (+) Hepatitis A (+) Bronchial asthma (-) Hypertension (-) Diabetes (-) Tuberculosis

16. PERSONAL/SOCIAL HISTORY • Farmer • Non-smoker • Non-alcoholic beverage drinker • No known allergies

17. REVIEW OF SYSTEMS (-) weight loss (-) fever (-) cough and colds (-) loss of appetite (-) easy fatigability (-) chest pain (-) palpitations

18. PHYSICAL EXAMINATION GS: conscious, coherent, ambulatory, not in respiratory distress VS: BP 100/70 HR 82 RR 18 T 36.9 HEENT: anicteric sclerae, pale palpebral conjunctivae, no nasoaural discharge, no CLAD CL: symmetric chest expansion, clear breath sounds

19. CVS: adynamic precordium, normal rate, regular rhythm, distinct S1 and S2 ABD: flat, normoactive bowel sounds, soft, (+) direct tenderness on LUQ, no guarding, no organomegaly EXT: no edema, no cyanosis, full and equal pulses

20. SALIENT FEATURES • 58 year-old female • farmer • left upper quadrant abdominal pain • abdominal CT scan finding of hepatic nodules

21. “What is the nature of the hepatic nodules?”

22. DAY OF ADMISSION • Primary Impression Hepatocellular carcinoma • Differential Diagnosis Liver Abscess

23. EB Abdominal Pain Hepatic Nodules Hepatocellular CA Liver Abscess Primary Metastatic Etiology??

24. CT Guided Liver Biopsy • CBC Gram Stain Culture and Sensitivity AFB Smear and Culture Cell Block

25. 1st HOSPITAL DAY • Patient had febrile episodes, maximum temperature of 39.4°C • Blood culture was done • Started on Metronidazole 50mg/IV q8° Ciprofloxacin 500mg/tab, 1 tablet 2x a day Paracetamol 500mg/tab, 1 tablet every 4 hours

26. 2nd HOSPITAL DAY • Patient still had febrile episodes • CBC done • Referred to Infectious Disease Service

27. “What is the focus of the fever?”

28. Patient was seen by the Infectious Disease Service Transfer IV site Urinalysis Chest x-ray

29. EB Liver Abscess UTI PTB Phlebitis Hepatocellular CA Etiology?? Primary Metastatic

30. 3rd HOSPITAL DAY • Patient was still febrile • Liver aspirate culture grew gram negative rods, T/C Pseudomonas

31. Ciprofloxacin was discontinued • Piperacillin-Tazobactam 4.5g/IV every 8 hours was started

32. 4th HOSPITAL DAY • Liver biopsy showed negative for malignant cells • Cytomorphologic features consistent with an acute suppurative infection

33. Liver aspirate culture grew Burkholderia pseudomallei • Piperacillin-Tazobactam was shifted to Ceftazidime 1g/IV every 8 hours

34. EB Liver Abscess PTB Hepatocellular CA Burkholderia pseudomallei Primary Metastatic

35. 5th HOSPITAL DAY • Blood culture and sensitivity showed no growth after 5 days • Day 1 afebrile

36. 6th HOSPITAL DAY • Day 2 afebrile • Patient decided that blood transfusion would be done in Isabela • Patient was discharged with follow-up after 2 months

37. FINAL DIAGNOSIS • Melioidosis • Cannot totally rule out Pulmonary Tuberculosis • Peptic ulcer disease

38. RECOMMENDATION • PTB work-up should be done

39. MELIOIDOSIS

40. HISTORICAL BACKGROUND • Named from the Greek “melis” (distemper of asses) and “eidos” (resemblance) • First described by pathologist Alfred Whitmore among morphia addicts in Burma in 1911 • In 1917, Stanton and Fletcher identified the bacteria that cause the disease

41. 100 cases identified during the French occupation of Vietnam in 1948-1954 • 300 cases identified during the American occupation in the 1970’s, popularly known as the “Vietnamese Time Bomb”

42. EPIDEMIOLOGY • Regarded as endemic to Southeast Asia and Northern Australia • Corresponds approximately to latitudes between 20oN and 20oS

43. Fig. 1 Worldwide distribution of melioidosis

44. REPORTED CASES • In Australia, 40 cases per 100,000 in 2002 • In Thailand, 1,100 cases between 2004-2005 • In Malaysia, 50 cases in 2002 • In Singapore, 57 cases in 2004 • In Taiwan, 43 cases in 2004 • In Philippines, not reported in the world literature

45. Burkholderia pseudomallei gram negative bacillus bipolar staining safety pin appearance saprophytic considered a Category 3 pathogen by the CDC ETIOLOGIC AGENT

46. Resilient organism capable of surviving hostile environmental conditions Produces several virulence factors: exopolysaccharides and lipase phospholipase C hemolysin protease Often called the Great Imitator

47. RISK FACTORS • Exposure to aquatic environments and agricultural lands • Diabetes mellitus • Chronic obstructive pulmonary disease • Use of steroids

48. CLINICAL SYNDROMES • Sepsis • Pneumonia • Liver abscess • Splenic abscess • Skin and soft tissue abscess

49. 4 DISEASE CATEGORIES (CDC, 2000) • Acute localized infection ▪ localized as a nodule ▪ results from inoculation through a break in the skin • Acute pulmonary infection ▪ produce a clinical picture ranging from mild bronchitis to severe pneumonia ▪ radiologic findings include nodule, upper lobe consolidation, cavitary lesions

50. Acute bloodstream infection ▪ patients with underlying illness such as diabetes, renal failure are affected by this type of disease ▪ usually results in septic shock • Chronic suppurative infection ▪ involves the liver, lung, spleen, lymph nodes ▪ may become dormant with exacerbation occurring after primary infection