Other Infections Involving the Liver

Pneumonia is the predominant clinical manifestation; abnormal liver biochemical test levels are frequent, usually without jaundice and without affecting the clinical outcome.

Liver histologic features are nonspecific, with portal infiltration, microvesicular steatosis, and focal necrosis; occasional organisms are seen.

Initial treatment is with a fluoroquinolone or macrolide antibiotic.

Multisystem disease caused by massive immune activation by superantigens: Staphylococcal toxic shock syndrome toxin (TSST-1), streptococcal toxic shock syndrome toxin (STSS), and other enterotoxins. S. aureus cases were described originally in association with tampon use and are now more frequently a complication of surgical wound infections, most commonly in the postpartum period. The case-fatality rate is 1.8% in menstrual cases and 5% in nonmenstrual cases. S. pyogenes cases are typically caused by invasive infections.

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  Typical findings include fever, a scarlatiniform rash (coarse rash with punctate dark papules on a diffuse erythematous base), mucosal hyperemia, vomiting, diarrhea, and hypotension, with rapid development of multiorgan failure. Hepatic involvement is almost always present, results from hypoperfusion and circulating toxins, and is marked by deep jaundice and high serum aminotransferase levels.

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  Liver histologic findings include microvesicular steatosis, necrosis, and centrilobular cholestasis.

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  The diagnosis is primarily clinical and infrequently confirmed by culture of toxigenic S. aureus or S. pyogenes or by demonstration of superantigens.

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  Treatment of S. aureus infection is with intravenous clindamycin plus nafcillin for methicillin-sensitive isolates or vancomycin or linezolid for methicillin-resistant isolates; S. pyogenes infection is treated with clindamycin and penicillin . Intravenous immune globulin may be beneficial in cases of Staphylococcus toxic shock syndrome, but data are more convincing for its use in cases caused by S. pyogenes.

Usually seen in association with a mixed anaerobic infection that results in rapid development of local wound pain, abdominal pain, and diarrhea, Clostridium perfringens infection is associated with myonecrosis or gas gangrene.

Jaundice may develop in up to 20% of patients with gas gangrene and is predominantly a consequence of massive intravascular hemolysis caused by the bacterial exotoxin, with resulting unconjugated hyperbilirubinemia.

Liver involvement may include abscess formation and gas in the portal vein.

The case survival rate is approximately 80%.

Treatment is with intravenous penicillin and clindamycin.

Infection caused by L. monocytogenes is characterized by meningoencephalitis and pneumonitis; hepatic involvement in adult human infection is rare.

Neonates, older adults, pregnant women, and patients with immune deficiency are most commonly affected.

Serum aminotransferase levels are typically high with liver involvement.

Patients may present with a single abscess, multiple microabscesses, or diffuse or granulomatous hepatitis; the outcome is worse with multiple abscesses.

Treatment is with ampicillin and gentamycin, typically for 3 to 4 weeks.

Half of all patients with disseminated gonococcal infection have abnormal liver biochemical test levels, mainly elevated serum alkaline phosphatase levels, and elevated aspartate aminotransferase (AST) levels. Jaundice is uncommon.

Perihepatitis (Fitz-Hugh − Curtis syndrome) is a common complication of gonococcal infection that affects women almost exclusively. It is believed to result from direct spread of infection from the pelvis and does not affect overall outcome. It can also be caused by infection with Chlamydia trachomatis.

Sudden onset of sharp right upper quadrant pain, often following lower abdominal pain as an indicator of long-standing pelvic inflammatory disease, is typical.

Fitz-Hugh−Curtis syndrome can be distinguished from gonococcal bacteremia by a characteristic friction rub over the liver and negative blood cultures. The diagnosis is made by nucleic acid amplification testing or culture. Laparoscopy may show characteristic “violin-string” adhesions between the liver capsule and the anterior abdominal wall.

Treatment is with intravenous ceftriaxone.

B. pseudomallei is a soil- and waterborne gram-negative bacterium that causes melioidosis; it is found predominantly in Southeast Asia and India. The clinical spectrum ranges from asymptomatic infection to fulminant septicemia.

Severe disease involves the lung, gastrointestinal tract, and liver, with hepatomegaly and jaundice; liver histologic changes include inflammatory infiltrates, multiple small and large abscesses, and focal necrosis.

Chronic disease is characterized by granulomas with central necrosis resembling tuberculous lesions. Organisms are rarely seen on Giemsa stains of liver biopsy specimens. The diagnosis can be made by serologic testing using an indirect hemagglutination assay, although this test remains positive after acute illness.

Initial antibiotic therapy consists of intravenous ceftazidime, imipenem, or meropenem.