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Correspondence

Indian Pediatr 2016;53: 1116

Primary Subphrenic Abscess in Infant

 

*Soumya Reddy and Naveen Nadig

Department of Pediatrics, Bapuji Child Health Institute and Research Center, Davangere, Karnataka, India.
Email: sr2390@gmail.com

  


A 4-month-old girl with insignificant past history presented to us with moderate grade fever for last four 4 days. Examination showed an afebrile, hemodynamically stable infant with hepatosplenomegaly and no obvious focus of infection. Blood investigations showed anemia, and negative dengue and malaria serology; the chest X-ray was normal. The fever persisted despite treatment with intravenous antibiotics (Ceftriaxone and Amikacin) for 48 hours. On the fifth day of hospitalization, a repeat blood panel showed leukocytosis, and a blood culture showed methicillin-resistant coagulase negative staphylococci. An ultrasound abdomen showed a right anterior subphrenic abscess. A diagnostic laparoscopy was performed to drain 20 mL of pus from the abscess between the diaphragm and liver. The post-procedure period was uneventful, and the infant recovered completely.

The right subphrenic space lies between the right lobe of the liver and diaphragm, and is one of the potential spaces for collection of pus under the diaphragm. A subphrenic abscess is usually secondary, with the primary disease process having a direct bearing on diagnosis, treatment and prognosis. It is seen most commonly with appendicitis, following hollow viscus perforation, as postoperative sequelae or in abdominal trauma [1]. The clinical manifestations are often obscured and varied, leading to delayed diagnosis, higher morbidity and mortality. Many of the symptoms and signs together make up a thoraco-abdominal clinical complex [1]. Swinging pyrexia, persistent hiccoughs, lung findings and tenderness on palpation in right hypochondrium are commonly noted. Radiography often reveals elevated hemidiaphragm, blunted costo-diaphragmatic angles and pulmonary infiltrates or atelectasis [2]. The bacteriological profile of these abscesses include aerobic and facultative bacteria like Escherichia coli, group D Enterococcus and Staphylococcus aureus; and less commonly, anerobic organisms like Bacteroides [3].

The subphrenic abscess occurs as a primary abscess without a causal lesion in only 4% of cases [1]. The focal lesion in these cases may be primary peritonitis or remote infection with hematogenous spread. Intra-abdominal abscess should be considered early on as a differential diagnosis for any child presenting with unexplained fever, leucocytosis, or poor antibiotic response.

References

1. Konvolinka CW, Olearczyk A. Subphrenic abscess. Curr Probl Surg.1972;1:1-51.

2. Schwab J, Gerber S, Benya E. A subphrenic abscess in a previously healthy child. Pediatrics. 1997;99:621-3.

3. Brook I. Intra-abdominal, retroperitoneal and visceral abscesses in children. Eur J Pediatr Surg. 2004;14:265-73.

 

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