Multiple Presumed Pyogenic Liver Abscesses Following Apparently Uncomplicated Acute Appendicitis in a Child: A Case Report
A. Lotfi *
Department of Pediatric Gastroenterology, Children’s Hospital of Rabat, Mohammed V University, Rabat, Morocco.
M. Sabib
Department of Pediatric Gastroenterology, Children’s Hospital of Rabat, Mohammed V University, Rabat, Morocco.
H. Berani
Department of Pediatric Gastroenterology, Children’s Hospital of Rabat, Mohammed V University, Rabat, Morocco.
T. Meskini
Department of Pediatric Gastroenterology, Children’s Hospital of Rabat, Mohammed V University, Rabat, Morocco.
S. Ettair
Department of Pediatric Gastroenterology, Children’s Hospital of Rabat, Mohammed V University, Rabat, Morocco.
*Author to whom correspondence should be addressed.
Abstract
Aims: To describe multiple presumed pyogenic liver abscesses developing shortly after appendectomy for acute appendicitis reported as uncomplicated in a child, and to highlight diagnostic uncertainty, portal venous findings, and management when drainage is considered unsafe.
Presentation of Case: A 7-year-old boy was admitted five days after appendectomy with fever, abdominal pain, and deterioration of his general condition. Haemoglobin was 3.5 g/dL, requiring red blood cell transfusion; white blood cell count was 24,800/mm³ and C-reactive protein was 261 mg/L. Ultrasonography and computed tomography showed multiple hepatic and pericholecystic collections, peritoneal effusion, hepatosplenomegaly, and portal cavernoma. Blood and ascitic fluid cultures were negative, and no abscess material was obtained for culture. After one week of a third-generation cephalosporin, an aminoglycoside, and metronidazole, fever and inflammation persisted; repeat computed tomography showed enlargement of the collections with capsular disruption. Treatment was escalated to intravenous imipenem, vancomycin, and metronidazole; heparin and enteral nutritional support were also initiated. Drainage was considered unsafe by the treating team because of concern for hepatic rupture. Intravenous antimicrobial therapy was continued for four weeks, with clinical and radiological improvement and a decrease in C-reactive protein to 60 mg/L. Portal cavernoma was already present on the initial imaging, and thrombophilia screening later showed reduced protein C activity.
Discussion: Appendicitis-associated liver abscesses are rare in children and are usually reported with perforated appendicitis or pylephlebitis. In this child, the appendicitis had been reported as uncomplicated, making the temporal association unusual. Because no abscess material was obtained, the pyogenic nature of the lesions remained presumptive. The chronology and significance of the portal cavernoma could not be established in the absence of previous imaging.
Conclusion: Persistent postoperative fever and abdominal symptoms should prompt abdominal imaging even after apparently uncomplicated appendicitis. When drainage is considered unsafe, prolonged antimicrobial therapy with close clinical and radiological monitoring may be effective in selected patients. A temporal association in a single case does not establish causality.
Keywords: Liver abscess, appendicitis, child, presumed pyogenic infection, portal cavernoma, case report