Causative Agents of Liver Abscess in Thai Hepatitis B Carriers

Liver abscess and hepatitis B virus (HBV) infection are two significant tropical
gastrointestinal disorders. The concurrence between these two disorders yields
poor prognosis, which then often leads to the need for intensive care. The aim of
this study was to investigate the causal pathogens of liver abscess in HBV carriers.
This retrospective case review was conducted on 35 Thai hospitalized HBV carriers
who had diagnosis of liver abscess. A high rate of amoebic liver abscess in this
series (37.1%) was demonstrated; Gram-negative aerobes were the major abscess
pathogens. The causative pathogens of HBV carriers were similar to those in the
overall patient population with abscess. The treatment plan for liver abscess in
the general population can also be applied to HBV carriers.

INTRODUCTION

Both liver abscess and HBV infection are important tropical gastrointestinal
disorders.[1] Liver abscess, although far less common than HBV infection, carries
a bad prognosis whatever the method of management.[2] In addition, the
concurrence between these two disorders yields poorer prognosis, leading to the
requirement for more intensive care.[3,4] However, there has been no previous
report concerning the causative pathogens of liver abscess in HBV carriers. The
purpose of the present study was to study the causal pathogens of liver abscess in
Thai HBV carriers.

MATERIALS AND METHODS

We performed a retrospective case review on 35 Thai hospitalized chronic HBV

carriers with liver abscess (16 males and 19 females, with an average age of 43.6 ±
20.3 years). The liver abscess was diagnosed by the same practice: ultrasound
and/or computed tomography scans, and according to pus from cavity aspiration
or surgery. To control the confounding interference factors, cases with other
coexisting liver diseases were excluded. Descriptive statistics by SPSS 7.0 for
Windows (SPSS Inc., Chicago, Illinois) were used in analyzing the patient
characteristics and laboratory parameters for each group.
RESULTS

According to this study, the abscesses were in the right lobe in 27 patients, in the
left lobe in 4, and in both lobes in 4. Twenty-eight patients had single abscess and
7 patients had multiple abscesses. Cultures from blood and pus were performed
in all 35 subjects. The causal pathogens from culture in abscess and blood are
listed in the Table. Ten had positive pus cultures and 5 had positive blood
cultures. No patient had more than 1 microorganism. Corresponding microbial
species were isolated from both blood and pus cultures in 4 patients. Six cases of
monomicrobial isolation were only identified from pus cultures. Of the negative
culture result cases, 13 (37.1%) presented both strong positive titer (> 1: 2048) for
indirect hemagglutination (IHA) test and positive microscopy, and were diagnosed
as amoebiasis. No patients with positive culture were also positive in IHA or
microscopy. Additionally, all cases positive for amoebiasis had negative culture
results. The other 12 cases with unknown causative pathogen were given
treatment as pyogenic liver abscess, and the patients improved. No cases in this
series died.
DISCUSSION

In our series, the abscesses were located predominantly in the right lobe of the
liver (77.2%), believed to be due to the liver vascularity, similar to those of
general patients (56% to 72%).[5,6] Also similar to general patients, most of our
patient had single abscess (80%).[7]
Of interest, we can demonstrate a high rate of amoebic liver abscess in our series
(37.1%). One possible explanation is the fact that most of other previous studies
are from temperate countries, which is not the endemic area of amoebiasis.[8]
We found positive cultures from blood and pus in 14.3% and 28.6% of patients,
respectively, while in general patients, the rates were reported to be 40% to 60%
from blood cultures and 73% to 92% from pus cultures.[8-10] Gram-negative
aerobes were the major abscess pathogens in our cases, similar to the general
patients.[11,12]
In addition, a case of Psuedomonas pseudomallei infection, melioidosis, was
detected; this may be attributed to the fact that melioidosis is a common tropical
infection in our setting.[1] Also, we did not find any case infected with anaerobe.
Of interest, this finding is not concordant with the previous bacteriology study of
liver abscesses in Taiwan, where the prevalence of HBV infection is very high,
which reported about 20% of anaerobes.[13] A possible explanation might be due
to the suppression of the growth of intestinal normal flora anaerobes according to
a study by Shutova and colleagues.[14] A further study with more subjects is
recommended to clarify this negative finding.
In conclusion, the concurrence between HBV infection and liver abscess can be
seen in medical practice. The causative pathogens of HBV carriers were similar to
those in general patients with abscess. The treatment plan for liver abscesses in
the general population can be applied for the HBV carriers. However, limitation
on the case inclusion due to the nature of a retrospective study should be
mentioned. Additional studies on the concurrence between the 2 diseases are
recommended.