Hepatobiliary infections due to non-capsulated Haemophilus influenzae

Abstract

We present two cases of non-capsulated Haemophilus influenzae hepatobiliary infection and review the literature. Such cases are rare, and prior to routine immunization against H. influenzae serotype b invasive Haemophilus disease was largely caused by capsulated strains. The epidemiology of invasive Haemophilus infections has changed and the number of cases of intra-abdominal and hepatobiliary infection may be underestimated due to current microbiological processing practices. Case reports Case 1A 52-year-old male patient was admitted following a 6 week history of gradually worsening right upper quadrant pain. In the preceding 24 h he had experienced fever and rigors, but with no other symptoms. Four years previously he had developed gall stone-induced pancreatitis that necessitated a cholecystectomy. Since then he was an insulin-dependent diabetic. His other past medical history included hypothyroidism that was well controlled with levothryoxine. On examination he had a temperature of 39.5 u C and was tachycardic with a pulse rate of 120 beats min 21 . He was hypoxic on room air with a pO 2 (partial pressure of O 2 in arterial blood) of 7.4 kPa and had respiratory alkalosis. There was no jaundice or abdominal tenderness. Blood tests revealed a raised white cell count of 19.2610 9 cells l 21 (neutrophilia) and a C-reactive protein level of 185 mg l 21 . Liver function tests showed an elevated alkaline phosphatase level of 247 IU l 21 with normal bilirubin (8 mmol l 21 ) and alanine transaminase (8 IU l 21 ). His international normalized ratio was elevated at 1.5, and he had an albumin level of 34 mg l 21 . Blood cultures taken on admission were sterile after 5 days incubation. An abdominal ultrasound scan identified a large cystic lesion (12 by 15 cm) also visualized by computed tomography (CT) scanning in segments 5, 6, 7 and 8 of the liver with appearances consistent with an abscess (Fig. 1). A CT pulmonary angiogram was normal (performed in view of the hypoxia). A percutaneous drain was inserted under ultrasound guidance that revealed pus that on culture gave a pure growth of Haemophilus influenzae. Empirical treatment had already been started with intravenous coamoxiclav (1.2 g three times daily) and this was continued for 14 days before the patient was discharged with a further 14 days of oral co-amoxiclav (625 mg three times daily). The patient's inflammatory markers normalized and a repeat liver CT scan 6 weeks later showed resolution of the abscess. Magnetic resonance cholangiopancreatography revealed no apparent biliary aetiology for the liver abscess. Case 2A 32-year-old female patient presented with a 6 day history of severe, colicky epigastric and left-sided upper quadrant pain that was exacerbated by movement and lying on her left side. This was associated with vomiting, fever and rigors. She had experienced similar but less severe bouts of pain over the preceding 2 years. Her past medical history included polycystic ovarian syndrome and a hiatus hernia, and her only regular medication was a proton ...

InvasiveHaemophilus influenzaeSerotype e and f Disease, England and Wales

“…Our results indicate that Hie and Hif share many features characteristic of invasive ncHi disease, such as patient age distribution, higher risk for infection among vulnerable populations, and higher CFR compared with Hib ( 7 ). Certain features that were previously attributed primarily to ncHi, such as causing hepatobiliary disease ( 28 , 29 ) and disease during pregnancy ( 30 ), were also observed among Hie and Hif case-patients, respectively, in our study. The proportion of case-patients with comorbidities in our cohort was similar to previous smaller studies (60%–80%) ( 13 , 27 , 31 – 34 ) and to that among ncHi case-patients ( 13 , 26 , 33 , 35 – 37 ).…”

Invasive Haemophilus influenzae Infections after 3 Decades of Hib Protein Conjugate Vaccine Use

“…Overall, pneumonia is the most frequent presentation, with invasive NTHi disease and NTHi pneumonia incidence increasing with age, particularly in older adults with underlying respiratory tract comorbidities, such as COPD and emphysema (204,208). Other clinical presentations, such as epiglottitis (once a characteristic of invasive Hib disease) and skeletal and soft tissue infections, are uncommon, but cholecystitis (209) and urolithiasis (210) appear to be a particular feature of invasive NTHi infection in adults. The morbidity rate of invasive NTHi infections is high in older adults.…”

Non-typeable Haemophilus influenzae, an under-recognised pathogen

“…The aforementioned Swedish study, for example, reported that 48% of 101 invasive NTHi cases had severe sepsis or septic shock and 20% required intensive care. 120 Reported case fatality ratio (CFR) for invasive NTHi disease range between 12-22%, 122,125,155,157,158,160 and is associated with age, clinical presentation, presence of co-morbidity and duration of follow-up after infection. In Europe, compared with Hib, the age-adjusted odds ratio for death from invasive NTHi disease was 2•4 (95% CI, 1•9-3•1, P < 0•0001) overall, 3•3 (95% CI, 1•5-7•5; P = 0•004) for pneumonia and 3•3 (95% CI, 1•5-7•5; P = 0•004) for bacteraemia, with no significant difference observed for meningitis.…”