Neonatal liver abscess is a rare entity, which usually occurs in preterm infants with sepsis and certain risk factors like umbilical vein catheterization. Neonatal hepatic abscess has a non-specific clinical presentation, and a high index of suspicion for this condition is warranted in case of unresolving sepsis especially in the presence of risk factors. Ultrasonography of abdomen is an important investigation in a febrile neonate with sepsis. Here, we report a case of hepatic microabscesses in a term neonate without any significant risk factors. We want to report this case because of its rare occurrence particularly in a term neonate without significant risk factors. This case also emphasizes the utility of abdominal ultrasonography in a febrile neonate with unresolving sepsis

Bafna, Sanjay

Bafna, Vibha

Kirthana, S B

Lad, Sagar

Ravikanth, Mergu

English

Atharva Scientific Publications (E-Jounals)

Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 228
Case Report
Case report of multiple hepatic microabscesses in a term neonate
Sanjay Bafna, S B Kirthana, Vibha Bafna, Sagar Lad, Mergu Ravikanth
From Department of Pediatrics, Jehangir Hospital, Pune, Maharashtra, India
Correspondence to: S B Kirthana, Department of Pediatrics, Jehangir Hospital, Pune, Maharashtra, India. Phone: +91-9591329885. 
E-mail: kirthanasb92@gmail.com
Received – 20 January 2018 Initial Review – 26 February 2018 Published Online – 14 April 2018
Neonatal liver abscess is a rare entity, and till date, 120 cases have been reported in literature [1]. In many babies dying of neonatal sepsis liver, microabscesses go 
undetected and are detected on postmortem examination [2]. In 
general, they occur in preterm infants with certain risk factors such 
as umbilical vein catheterization, systemic sepsis, necrotizing 
enterocolitis, and total parenteral nutrition catheters [2-4]. Thus, a 
strong index of suspicion is needed for this condition in neonates 
suffering with unresolving sepsis with above risk factors. Here, 
we report a case of hepatic microabscesses in a term neonate. 
This baby did not have any of the known risk factors for hepatic 
microabscesses. Although this baby had low birth weight; it is not 
a risk factor mentioned in literature for hepatic microabscesses 
and it was a full term baby. Neonates with this condition present 
with non-specific features similar to sepsis and diagnosis may be 
established only after ultrasonography.
CASE REPORT
A male neonate with birth weight of 1.9 kg was born of emergency 
lower segment cesarean section in view of per vaginum leak 
for 6–8 h at 37 weeks of gestation. Mother was primigravida 
aged 34 years with no other significant antenatal risk factors. 
Baby presented, on 12th day of life, with high fever, decreased 
activity, and feeding since 1 day. On examination, the baby was 
febrile, lethargic and had signs of poor perfusion. On abdominal 
examination, the baby did not have organomegaly or abdominal 
distension. Rest of the systemic examination was normal.
The baby was admitted to neonatal intensive care unit and was 
given fluid bolus and started on intravenous fluids. Investigations 
showed polymorphonuclear leukocytosis, high C-reactive 
proteins (91 mg/dl) with normal urine and cerebrospinal fluid 
examination. He was started on intravenous cefotaxime and 
amikacin after sending cultures. Dopamine was started as he 
continued to have poor perfusion. At 48 h there was a partial 
clinical improvement, however, in view of rising C-reactive 
proteins (118 mg/dl) and tentative growth in cultures of blood and 
urine; antibiotics were stepped up to intravenous meropenem and 
linezolid. Liver function tests were normal (total bilirubin -1.64, 
direct bilirubin - 0.1, indirect bilirubin - 1.54, and alanine 
aminotransferase - 25.9IU).
Ultrasonography of abdomen done in view of suspected 
urinary tract infection showed a normal urinary system with an 
incidental finding of multiple microabscesses in the liver largest 
measuring 1.5 cm (Fig. 1). Blood culture grew Staphylococcus 
aureus resistant to ampicillin, penicillin, amoxiclav and sensitive 
to cephalosporins, linezolid, clindamycin and amikacin. Serial 
ultrasonography of abdomen showed partial regression of hepatic 
microabscesses. Intravenous antibiotics meropenem and linezolid 
were given for 14 days; the baby was discharged with oral 
linezolid for 14 days. Ultrasonography of abdomen on follow-up 
after 1 week showed complete resolution of all microabscesses. 
Baby is well with good weight gain.
DISCUSSION
Neonatal liver abscess is a rare entity, and till date, 120 cases 
have been reported in literature [1]. Reported number of this 
rare condition amounts to 27 in past 6 years [2]. Among 7500 
autopsies from 1917 to 1967, only 3 neonates had multiple liver 
microabscesses [5]. In general, they occur in preterm infants 
with certain risk factors like umbilical vein catheterization [2]. 
ABSTRACT
Neonatal liver abscess is a rare entity, which usually occurs in preterm infants with sepsis and certain risk factors like umbilical vein 
catheterization. Neonatal hepatic abscess has a non-specific clinical presentation, and a high index of suspicion for this condition 
is warranted in case of unresolving sepsis especially in the presence of risk factors. Ultrasonography of abdomen is an important 
investigation in a febrile neonate with sepsis. Here, we report a case of hepatic microabscesses in a term neonate without any 
significant risk factors. We want to report this case because of its rare occurrence particularly in a term neonate without significant 
risk factors. This case also emphasizes the utility of abdominal ultrasonography in a febrile neonate with unresolving sepsis.
Key words: Hepatic abscess, Neonate, Sepsis, Staphylococcus aureus
Bafna et al. Hepatic microabscesses in a term neonate
Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 229
Systemic sepsis, necrotizing enterocolitis, and central parenteral 
nutrition catheters are the other risk factors [3,4]. Our neonate 
was a term neonate with low birth weight, with no other risk 
factors. Gram-negative enteric bacteria and S. aureus were the 
most common organisms isolated [6] (Table 1). Simeunovic 
et al. did a retrospective chart review of six neonates diagnosed 
with hepatic abscesses from 2000 to 2006. Five of them were 
preterm and common organisms implicated were Klebsiella (3), 
Staphylococcus (3), Gonococcus (1), and Enterobacter (1) [7] 
(Table 1). In our case blood, the culture grew S. aureus.
The classical presentation of liver abscess with fever, 
hepatomegaly, and right upper abdominal pain is generally not 
present in neonates. The signs and symptoms are nonspecific 
and are essentially those of sepsis or secondary metastatic 
complications such as meningitis, pneumonia, or peritonitis [8]. 
Our neonate had features of sepsis, with poor perfusion presenting 
on day 12 of life with no hepatomegaly. Baby showed partial 
improvement by day 3 of antibiotic therapy. Ultrasonography of 
abdomen done in view of suspected urinary tract infection led 
to the incidental detection of multiple hepatic microabscesses. 
We upgraded the antibiotics to intravenous meropenem and 
linezolid with clinical improvement and gradual resolution of 
microabscesses.
Tan et al. reported 6 preterm neonates with hepatic abscess 
who had clinical features of unresolving sepsis with persistent 
positive blood culture even after appropriate antibiotic therapy. 
This led them to investigate these babies with ultrasonography of 
hepatobiliary system [6]. Similarly, De Franco et al. reported a case 
of term neonate with hepatic abscess. This baby was ventilated 
for meconium aspiration syndrome and had an umbilical vein 
catheter line inserted. The baby developed unresolving sepsis in 
2nd week of life with glomerulonephritis and persistent growth in 
Table 1: Details of previous studies
Study and 
year of 
publication
No. of 
term/
preterm
Clinical features Risk factor Type of liver 
abscess
Treatment Organism Outcome
Semerci 
et al., 
2016 [1]
3 preterms Severe sepsis not 
responding to IV 
antibiotics
Prematurity, 
late-sepsis, 
umbilical 
catheterization, 
necrotizing 
enterocolitis, 
previous 
antibiotic therapy
Solitary hepatic 
abscess
IV antibiotics Staphylococcus spp. in two 
cases and Pseudomonas 
spp. in one case
Responded 
well to 
antibiotic 
therapy alone
Singh et al., 
2015 [13]
1 term at 
day of life 
12
Persistent positive 
blood culture 
despite antibiotics
IV fluids for 
respiratory 
distress initial 
2 days of life
Multiple 
microabscesses
vancomycin 
and 
cloxacillin
Staphylococcus aureus Recovered 
baby had 
associated 
portal vein 
thrombosis 
which resolved 
with treatment 
of hepatic 
abscess
Simeunovic 
et al., 
2009 [7]
6
5 preterm 
1 post 
mature
Sepsis signs
Tender 
hepatomegaly
Ileus
Preterm, 2 had 
malpositioned 
UVC
3 - medical
2 - needle asp
1 -open 
drainage
3 - Klebsiella
3 - Staphylococcus aureus
Recovered
Lam et al., 
2005 [3]
1 preterm Abdominal 
distension? 
Perforation
Preterm, 
Malposition of 
UVC
Moens et al., 
2003 [14]
2 preterms Persistent sepsis Preterm, UVC Solitary abscess Percutaneous 
drainage with 
iv antibiotic
One child pus has staph 
epidermidis
Another one was sterile
Recovered
De Franco 
et al., 
2000 [9]
1 term Persistent sepsis 
and presence of 
glomerulonephritis
Baby had MAS 
on ventilator, had 
UVC
Solitary abscess Surgical 
drainage with 
iv antibiotics
Coagulase-negative staph Recovered
Tan et al., 
2005 [6]
6 preterms Persistent positive 
blood culture 
despite antibiotics
Preterm, UVC 2 babies had 
solitary
2 needed 
surgical 
drainage
Chryseobacterium gleum, 
MRSA, Candida albicans, 
Acinetobacter, Klebsiella
3 died
Kandall 
et al., 
1974 [15]
1 
neonate
Sepsis died at 
day 25
- Solitary 
abscess - at 
postmortem 
examination
- - -
MRSA: Methicillin‑resistant Staphylococcus aureus
Bafna et al. Hepatic microabscesses in a term neonate
Vol 5 | Issue 3 | Mar 2018 Indian J Child Health 230
blood culture even after 1 week of antibiotics [9] (Table 1).
Thus, undetected hepatic microabscesses could be a cause for 
unresolving sepsis, and high index of suspicion for this condition 
is warranted in such a scenario. The hepatic abscess can be either 
multiple or solitary. Multiple liver abscesses are multiple, small 
in size, not drainable, usually not due to umbilical infection and 
have a fulminant course. Whereas solitary liver abscess is larger, 
well localized, can be drained by surgical methods and has a sub-
acute course [10]. Ultrasonography of abdomen is the reliable initial 
imaging study in the newborns with clinical suspicion of hepatic 
abscess. Computerized tomography (CT)/magnetic resonance 
imaging with contrast is another modality which is rarely needed. 
Open surgical drainage with intravenous antibiotics is the traditional 
treatment-employed for a solitary hepatic abscess. Presently, 
CT guided percutaneous drainage with intravenous antibiotics 
is preferred with ultrasonography monitoring for resolution. 
Microabscesses usually resolve with conservative management [11]. 
In a case series reported by Tan et al., out of 6 neonates, 2 were 
required surgical drainage, and 4 were managed conservatively. 
Three of these neonates died of fulminant hepatic failure [6].
Duration of treatment is based on clinical response with 
parenteral treatment recommended for at least 2 weeks [5]. 
Duration of antibiotics should be for a minimum period of 
3 weeks [12]. Our neonate was given meropenem and linezolid 
for 14 days followed by oral linezolid for 14 days. There was 
complete resolution of all abscesses and baby is doing well with 
good weight gain on follow-up.
CONCLUSIONS
Neonatal hepatic abscess has non-specific clinical presentation 
similar to sepsis and a high index of suspicion for this condition is 
warranted in case of unresolving sepsis especially in the presence 
of risk factors. Ultrasonography abdomen is an important 
investigation in a febrile neonate with sepsis; especially with 
organisms like staphylococcus which has propensity to cause 
seeding in multiple organs. Early recognition and treatment of 
hepatic abscess with intravenous antibiotics may prevent the 
need for surgical intervention and will also reduce the mortality 
and morbidity associated with the untreated and partially treated 
cases.
REFERENCES
1. Semerci SY, Babayigit A, Cebeci B, Buyukkale G, Cetinkaya M. Hepatic 
abscesses in preterm infants: Report of three cases and review of the 
literature. J Trop Pediatr 2016;62:255-60.
2. Oktav B, Moralioglu S, Celayir AC, Pektas O. Liver abscess: Increasing 
occurrence in premature newborns. J Neonat Surg 2013;2:23.
3. Lam HS, Li AM, Chu WC, Yeung CK, Fok TF, Ng PC, et al. Mal-positioned 
umbilical venous catheter causing liver abscess in a preterm infant. Biol 
Neonate 2005;88:54-6.
4. Tariq AA, Rudolph N, Levin EJ. Solitary hepatic abscess in a newborn 
infant: A sequale of umbilical vein catheterization and infusion of hypertonic 
glucose solutions. Clin Pediatr 1974;13:1081-2.
5. Overturf GD. Infections of liver chap 10. In: Remington J, Klein J, Baker W, 
editors. Infectious Diseases of Fetus and Newborn, 8th ed. Philadelphia: 
Elsivier Saunders; 2015. p. 1092-100.
6. Tan NW, Sriram B, Tan-Kendrick AP, Rajadurai VS. Neonatal hepatic 
abscess in preterm infants: A rare entity? Ann Acad Med Singapore 
2005;34:558-64.
7. Simeunovic E, Arnold M, Sidler D, Moore SW. Liver abscess in neonates. 
Pediatr Surg Int 2009;25:153-6.
8. Moss TJ, Pysher TJ. Hepatic abscess in neonates. Am J Dis Child 
1981;135:726-8.
9. De Franco PE, Shook LA, Goebel J, Lee B. Solitary hepatic abscess with 
associated glomerulonephritis in a neonate. J Perinatol 2000;20:384-6.
10. Sharma S, Mohta A, Sharma P. Hepatic abscess in a preterm neonate. Indian 
Pediatr 2007;44:226-8.
11. Diamet MJ, Stanle YP, Kangarlo OH. Percutaneous aspiration and catheter 
drainage of abcesses. J Pediatr 1986;108:204.
12. Novak DA, Dolson DJ. Bacterial, parasitic and fungal infections of the liver. 
In: Suchy FJ, editor. Liver Disease in Children. St.Louis: Mosby; 1994. 
p. 550-68.
13. Singh D, Venkateshwar V, Bhatia M. Neonatal hepatic abscess with resolving 
portal vein thrombosis. Med J Armed Forces India 2015;71:82-4.
14.  Moens E, Dooy JD, Jansens H, Lammens C, Op de Beeck B, Mahieu L, 
et al. Hepatic abscesses associated with umbilical catheterisation in two 
neonates. Eur J Pediatr 2003;162:406-9.
15. Kandall SR, Johnson AB, Gartner LM. Solitary neonatal hepatic abscess. 
J Pediatr 1974;85:567-9.
Figure 1: Ultrasonography of liver showing multiple microabscesses 
largest measuring 1.5 cm.
Funding: None; Conflict of Interest: None Stated.
How to cite this article:  Bafna S, Kirthana SB, Bafna V, Lad S, Ravikanth M. 
Case report of multiple hepatic microabscesses in a term neonate. Indian J 
Child Health. 2018; 5(3):228-230.


Case report of multiple hepatic microabscesses in a term neonate

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Case report of multiple hepatic microabscesses in a term neonate

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