A 4½-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 . 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 . 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 . 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 .
The subphrenic abscess occurs as a primary abscess
without a causal lesion in only 4% of cases . 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.
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2. Schwab J, Gerber S, Benya E. A subphrenic abscess
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3. Brook I. Intra-abdominal, retroperitoneal and visceral abscesses
in children. Eur J Pediatr Surg. 2004;14:265-73.