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Journal of Clinical Microbiology, March 1998, p. 818-819, Vol. 36, No. 3
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
Haemophilus parainfluenzae Liver Abscess
after Successful Liver Transplantation
J.
Friedl,*
A.
Stift,
G. A.
Berlakovich,
S.
Taucher,
M.
Gnant,
R.
Steininger, and
F.
Mühlbacher
Department of Surgery, Division of
Transplantation Surgery, University of Vienna, Vienna, Austria
Received 29 September 1997/Returned for modification 1 November
1997/Accepted 18 December 1997
 |
ABSTRACT |
Haemophilus parainfluenzae was isolated from a bile
specimen and from an aspirate of a liver abscess in a 58-year-old
liver-transplanted woman that was indicative of an invasion of the
graft by an ascending route. Drug therapy, immunosuppression, rejection
therapy, and Roux-en-Y choledochojejunostomy may have contributed to
the septic course. Interdisciplinary cooperation was instrumental in
diagnosis and successful management in this case.
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TEXT |
Infectious complications remain a
major cause of morbidity and mortality after liver transplantation. The
incidence of bacterial infections after liver transplantation differs
considerably among transplantation centers, and reported infection
rates range between 35 and 68% (1, 2, 8, 9, 12, 15).
Patients under immunosuppressed conditions are at higher risk for
infections and, in general, for infections which are caused by
bacterial pathogens that are normally nonpathogenic. Herein we describe a patient who developed a nonbacteremic Haemophilus
parainfluenzae liver abscess 1 year after successful orthotopic
liver transplantation. H. parainfluenzae, a commensal
organism of the upper respiratory tract, is an uncommon agent of human
infection. It has been found to be associated with soft tissue
infections, septic arthritis, genital tract infections, meningitis and
brain abscesses (3), upper respiratory tract infections
(10), endocarditis, bacteremia (7), and
osteomyelitis (2). To date, only two cases of H. parainfluenzae liver abscess have been reported (3, 6).
Case report.
A 58-year-old woman was admitted to our
hospital 1 year after liver transplantation for extrahepatic
cholangiocarcinoma. She was suffering from recurrent fever attacks and
cholestasis. The diagnosis of purulent cholangitis,
choledocholithiasis, and common bile duct stenosis was made. Despite
stenting of the bile duct stricture, the patient acquired
multiple infections (recurrent cholangitis and urinary tract
infection) with different bacterial strains, including
Klebsiella oxytoca, Pseudomonas spp.,
Staphylococcus aureus (methicillin resistant), a
coagulase-negative staphyloccocus, and Streptococcus
faecium. Vancomycin and rifampin or ciprofloxacin were used for
treatment. Three weeks after the last infection, liver enzyme levels
increased and a liver biopsy was performed, revealing graft rejection.
A steroid pulse was given, and the immunosuppressive regimen was
switched from cyclosporine (CsA) to tacrolimus and azathioprine. Three
days later, the patient had fever again and a blood culture yielded
methicillin-resistant S. aureus and Streptococcus
faecalis. Vancomycin was readministered for 1 week until a
Roux-en-Y choledochojejunostomy was performed. Vancomycin was also
used as an intraoperative as well as a perioperative agent in
combination with metronidazole. Intraoperative bile samples were
obtained, and H. parainfluenzae and Enterococcus
faecalis were isolated. Two weeks after the Roux-en-Y
choledochojejunostomy, the patient had recurrent fever attacks with
negative blood cultures. An abdominal computed tomography scan was
performed, showing a hypodense area in the eighth liver segment. A
fine-needle aspiration was done, and an initial Gram stain of the
aspirate showed gram-negative coccobacilli. Since the further testing
identified the isolate as H. parainfluenzae, daily
intravenous treatment with fleroxacin led to a favorable outcome. Three
years after liver transplantation, the patient is well with normal
graft function.
Discussion.
H. parainfluenzae is a commensal organism of
the oropharynx and is present in over 20% of fecal samples analyzed
(14). To date, only two cases of H. parainfluenzae biliary tract infections and only two H. parainfluenzae liver abscesses have been documented (Table
1). None of these infections was
associated with bacteremia. This may indicate that H. parainfluenzae infection occurs via an ascending route. Two
factors support this hypothesis. First, H. parainfluenzae
grows well in the presence of V factor, which is abundant in the
duodenum (11). Second, H. parainfluenzae bears
iron-repressible outer membrane proteins closely related to those of
enteric bacteria. These proteins may serve as adhesins, allowing
colonization of the intestinal tract mucosa (13). Once H. parainfluenzae is established, it is provided with
abundant V factor (NAD) excreted by the local flora.
Our report strongly supports this hypothesis because an
H. parainfluenzae liver abscess was evident after
H. parainfluenzae was isolated from the common bile duct and
blood cultures showed
no concomitant bacteremia. There are some
possible reasons why
this ascending infection occurred. One is that the
patient suffered
from recurrent cholangitis with concomitant
cholestasis, which
allowed bacterial overgrowth. This overgrowth was
supported by
graft rejection therapy, switching of the
immunosuppression therapy,
and Roux-en-Y choledochojejunostomy.
Metronidazole is widely distributed. It appears in most body tissues,
including bile, bone, liver, brain, breast milk, saliva,
and seminal
fluid, and achieves concentrations similar to those
in plasma.
Metronidazole is metabolized by side chain oxidation
and glucuronide
formation, and the majority of a dose of metronidazole
is excreted in
the urine, mainly as metabolites. Some of the metabolites
also have
antibacterial activity (
16). Thus, metronidazole,
in
contrast to vancomycin, which is not excreted in bile, may
have induced
a change in the local bacterial flora. To prevent
a further infection
in that critical situation, we treated the
patient with fleroxacin,
although the susceptibility profile of
the isolated strain indicated no
resistance to any of the tested
agents, including
amoxicillin-clavulanic acid, aminopenicillin
derivatives,
tetracyclines, and expanded- and broad-spectrum cephalosporins.
It seems that the combination of the factors mentioned above was
responsible for the rapid ascending progression from a localized
infection of the common bile duct to a general condition of sepsis
due
to a liver abscess.
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FOOTNOTES |
*
Corresponding author. Mailing address: Dept. of
Surgery, Division of Transplantation Surgery, AKH Vienna,
Währinger Gürtel 18-20, A-1090 Vienna, Austria. Phone: 43 1 40400 5621. Fax: 43 1 40400 5642. E-mail:
Josef.Friedl{at}akh-wien.ac.at.
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Journal of Clinical Microbiology, March 1998, p. 818-819, Vol. 36, No. 3
0095-1137/98/$04.00+0
Copyright © 1998, American Society for Microbiology. All rights reserved.
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