Pyogenic hepatic abscess: clues for diagnosis in the emergency room

CONCISE COMMUNICATIONS

Confirmation of meningococcal disease by urinary antigen testing

S. C. Clarke�, J. Reid, L. Thom and G. F. S. Edwards

Scottish Meningococcus and Pneumococcus Reference Laboratory, House on the Hill, Stobhill Hospital,

Glasgow G21 3UW, UK

�Tel/Fax: þ44 141201 3836 E-mail: [email protected]

The meningococcus is an important cause of morbidity and mortality and a rapid laboratory diagnosis

is required through accurate, non-culture-based methods. Body fluids that are easily obtainable are preferred

for this route of diagnosis and urine is the specimen of choice as it can be obtained non-invasively. Urine

samples were tested from patients with suspected meningococcal disease and tested by latex agglutination

and PCR. It was shown that urinary PCR is not useful for the laboratory confirmation of MD but latex

agglutination testing may be useful in certain settings prior to confirmatory testing by a reference laboratory.

Keywords Urine, meningococci, antigen, polymerase chain reaction

Accepted 3 July 2001

The meningococcus is one of the main causes of meningitis,

particularly in countries where conjugate vaccines against

Haemophilus influenzae type b disease have been introduced,

and is an important cause of morbidity and mortality [1,2]. The

search for new therapeutic and diagnostic methods therefore

continues, with the aims of reducing the morbidity and

mortality associated with meningococcal disease (MD), and

performing effective surveillance of the disease. Although

polysaccharide vaccines have been available for the prevention

of a number of serogroups of MD, these vaccines have generally

had a short duration of protection and could not be used in

young children. New conjugate vaccines are now available for

the prevention of serogroup C MD [3,4], but there are no

conjugate vaccines yet available for the prevention of other

invasive meningococcal serogroups.

As technology improves, new methods are becoming avail-

able for the laboratory confirmation of MD. These include

PCR and DNA sequencing methods [5,6]. Automation is also

becoming increasingly used as it becomes affordable [7]. How-

ever, most of these methods are limited to specialised labora-

tories and therefore result in reporting delays. To enable a rapid

diagnosis of MD to be made local diagnostic microbiology labo-

ratories require access to quick but accurate methods [8]. Owing

to the common use of antibiotics prior to hospital admission

[9], non-culture confirmation of disease is important, although

every effort should be made to gain a culture confirmation.

Methods are therefore required that can provide a rapid,

accurate and non-culture diagnostic route to confirm a clinical

suspicion of MD. Body fluids that are easily obtainable are

preferred for this route of diagnosis, and urine is the specimen of

choice, because it can usually be obtained non-invasively. As all

PCR requests for the laboratory confirmation of MD in

Scotland are forwarded to the ScottishMeningococcus andPneu-

mococcus Reference Laboratory (SMPRL), and there is a delay

due to postal and testing time, testing for urinary antigen would

be a rapid and cost-effective screening method for MD in a local

diagnostic laboratory. Urines that are positive by latex agglu-

tination could then be forwarded to the reference laboratory for

further testing. Two preliminary studies have been performed

for the rapid detection of meningococcal antigen in urine

[10,11], but the number of samples used was small. Here we

describe the usefulness of latex agglutination and PCR testing

on unconcentrated and concentrated urine for the laboratory

confirmation of MD.

A request was made to all diagnostic microbiology labora-

tories throughout Scotland to send urine samples from patients

suspected of having MD. Urines were taken at the onset of

illness and sent to the SMPRL for testing. All testing was

performed on unconcentrated and concentrated urine. Uncon-

centrated urine was boiled for 5 min Concentration of urine was

initially performed with 5 mL, using the commercially avail-

able Millipore Minicon B15 concentration system (Amicon,

Millipore, Watford, UK), according to the manufacturer’s in-

structions. However, this was found to result in inhibition of the

PCR reaction, and was therefore replaced with the Vivapore 5

(Sartorius, Epsom, Surrey, UK), a similar method that could be

used for comparison. After concentration, the urine was again

boiled for 5 min Unconcentrated and concentrated urines were

tested for the presence of meningococcal antigen using the

Wellcogen latex agglutination test (Abbot Diagnostics, Maiden-

head, UK). Urines that were positive for serogroups A, C, Yand

W135 by latex agglutination were tested further by coagglu-

tination to determine the individual serogroup [12]. Uncon-

centrated and concentrated urines were also tested for the

presence of meningococcal antigen, using PCR to detect

the insertion element IS1106, as previously described [13,14].

Between August 1999 and July 2000, a total of 133 urines

were received from 128 patients and tested for the presence of

� 2001 Copyright by the European Society of Clinical Microbiology and Infectious Diseases

meningococcal antigen as described. The first 59 urines were

tested by the Millipore Minicon B15 method, and eight urines

were positive for meningococcal antigen by latex agglutination,

as previously reported [11]. Five of these were serogroup B, and

three were serogroup C. The remaining 51 urines were negative

by latex agglutination. Only one urine of these 51 was positive

by PCR after concentration (urine 9, Table 1), and it had been

negative by latex agglutination. Further testing on this patient

by a meningococcal outer membrane protein (OMP) serum

antibody ELISA method suggested that the patient did not have

MD. PCR inhibition factors were present in eight (14%)

unconcentrated urines and 19 (32%) concentrated urines.

Owing to the high number of urines possessing these inhibition

factors after concentration using the Millipore system, the

concentration technique was replaced with the Vivapore 5

system. A further 74 urines were tested by latex agglutination

and PCR. No urines were positive by either latex agglutination

or PCR when unconcentrated or concentrated samples were

used. Inhibition factors were again common, being found in 37

(50%) of samples. Summarised results are shown in Table 2.

Antigen detection tests are routinely used by the SMPRL and

can provide sensitive and specific methods for the confirmation

of MD [6]. Blood or cerebrospinal fluid are the samples

routinely used for antigen detection, because urine has never

been evaluated for its usefulness. However, it is well known that

latex agglutination tests, although highly sensitive, often pro-

duce false positives, particularly in the presence of proteins

normally found in urine [15]. Latex agglutination could be used

as a screening assay, followed by the PCR test as a more sensitive

and specific assay, with the possibility of confirming the

serogroup of infection using the siaD PCR method [16]. In

this study, 133 urine samples from 128 patients with suspected

MD were analyzed. Concentration of the urine did not affect

the latex agglutination result. Three of the latex agglutination-

positive urines were confirmed by other methods, while the

other five were not confirmed, either because other tests were

negative or because no other samples were received. Latex

agglutination of urine for the confirmation of MD may there-

fore be useful as an urgent measure for confirming and obtain-

ing the serogroup of the infecting meningococcus in local

diagnostic laboratories where PCR testing is not available.

Further testing and confirmation may then be achieved at a

reference laboratory, where other tests using samples other than

urine, such as whole blood or cerebrospinal fluid, may be used.

The urinary PCR test was not useful for the laboratory

confirmation of MD. All but one of the urines tested were

negative for the insertion element IS1106, using both uncon-

centrated and concentrated urine. The concentrated urine that

was positive by PCR was not confirmed by other methods and

may have been a false-positive result. The concentration of

urine using either commercial system increased the number of

urines that exhibited factors resulting in inhibition of the PCR

reaction. These factors may cause such inhibition by reducing

the amount of available magnesium ions in the PCR reaction

mix [17]. Although this can be counteracted by increasing the

magnesium ion concentration, the variability in the amount of

inhibitor may result in a less rigid PCR assay for clinical

diagnostic use. Normally, the IS1106 PCR assay is very useful

for the laboratory confirmation of MD using other body fluids,

such as whole blood or cerebrospinal fluid [6]. Although false-

positive results using this gene target have been reported [18],

this was generally not a problem in this study. True positives can

often be confirmed by other slightly less sensitive PCR assays

that detect the ctrA and siaD genes, respectively [5,16], although

this was not the case for this positive.

REFERENCES

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Meningococcal Dis 1995; 7: 159–75.

2. Noah N, Henderson B. Surveillance of bacterial meningitis in Europe

1997/98. London: Public Health Laboratory Service, 1998.

3. Chief Medical Officer. Introduction of immunisation against group

C meningococcal infection. PAL51979. Health Department, Scotland,

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4. Chief Medical Officer. Start of the New Meningococcal C Conjugate

Vaccine Immunisation Programme. PL/CMO/99/4. London: De-

partment of Health, England and Wales, 1999.

5. Guiver M, Borrow R, Marsh J et al. Evaluation of the Applied

Biosystems automated Taqman polymerase chain reaction system

for the detection of meningococcal DNA. FEMS Immunol Med

Microbiol 2000; 28: 173–9.

6. Clarke SC, Edwards GFS. Guidance for requests and interpreta-

tion of services provided by the Scottish Meningococcus and

Table1 Positive results fromantigen testingof unconcentrated andconcen-

trated urine by latex agglutination and PCR

UrineLatexserogroup

UnconcentratedPCR

ConcentratedPCR

1 B Negative Negative


3 B Negative Inhibitor present


5 C Negative Inhibitor present

6 C Negative Negative


8 C Negative Negative

9 Negative Negative Positive

Table 2 PCR inhibition information using two commercially available con-

centration systems

Commercial system Unconcentrated Concentrated

Minicon B15 8 (16%) 19 (37%)

Vivapore15 15 (20%) 37 (50%)

566 Clinical Microbiology and Infection, Volume 7 Number 10, October 2001

� 2001 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 7, 565–570

Pneumococcus Reference Laboratory. SCIEH Weekly Rep 2000;

34: 228–32.

7. Clarke SC, Diggle MA, Reid JA, Thom L, Edwards GFS.

Introduction of an automated service for the laboratory

confirmation of meningococcal disease in Scotland. J Clin Pathol

2001; 54: 556–7.

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latex immunoagglutination and PCR as complementary methods

for non-culture-based confirmation of meningococcal disease.

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enteral penicillin in meningococcal disease. Br Med J 1992; 305: 484.

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than PCR in the diagnosis of meningococcal disease. J Hosp Infect

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11. Clarke SC. Urinary antigen diagnosis of meningococcal disease. Br

J Biomed Sci 2000; 57: 153–5.

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grouping of meningococci and detection of antigen in cere-

brospinal fluid by coagglutination. Med Lab Sci 1978; 35: 63–6.

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16. Borrow R, Claus H, Guiver M et al. Non-culture diagnosis and

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sialyltransferase (SiaD) PCR ELISA. Epidemiol Infect 1997; 118:

111–17.

17. Abu Al-Soud W, Radstrom P. Purification and characterization of

PCR-inhibitory components in blood cells. J Clin Microbiol 2001;

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meningococcal infection by the IS1106 PCR ELISA. FEMS

Microbiol Lett 1998; 162: 215–18.

Pyogenic hepatic abscess: clues for diagnosis in the emergency roomJ. L. Hernandez and C. Ramos

Department of Internal Medicine, Hospital Marques de Valdecilla, Santander, Spain

E-mail: [email protected]

The objective of this paper is to describe the clinical and diagnostic characteristics of patients with

pyogenic hepatic abscesses evaluated in the emergency room, and to know whether it is feasible to make an

early diagnosis based on any of these characteristics. The setting was an urban, tertiary-care teaching

hospital. This was a retrospective study of 63 adult patients admitted to our institution because of

pyogenic liver abscesses from January 1991 to December 1998.

Keywords Liver abscess, emergency care, diagnosis

Accepted 8 June 2001

Clin Microbiol Infect 2001: 7: 567–570

INTRODUCTION

Pyogenic hepatic abscess (PHA) represents an infrequent and

sometimes life-threatening entity [1]. Its recognition has clearly

improved in the last decade through the development of more

sensitive and specific imaging techniques, such as ultrasono-

graphy (US) and computed tomography (CT), with their

relevant therapeutic implications [2,3]. Standard treatment

protocols usually recommend a combination of drainage and

antimicrobial therapy, although no specific antibiotic schemes

have been defined due to the lack of large, prospective studies [4].

Diagnosing PHA in an initial stage remains a difficult task

today, frequently due to the paucity of the presenting symptoms

or the radiological features. However, several studies have

confirmed that an early diagnosis is associated with improved

survival [5–7].

This study will describe the clinical and diagnostic charac-

teristics of patients with PHA evaluated at a first-step hospital

level, the emergency room (ER).

PATIENTS AND METHODS

The medical records of all adult patients admitted between

January 1991 and December 1998 at the Marques de

Valdecilla University Hospital, and discharged with a diagnosis

of PHA, were reviewed. This is an 1100-bed tertiary-care center

that serves as the reference hospital for a population of 500 000,

and as the first-level hospital for an area including about 350 000

inhabitants in Northern Spain. Therefore, this population

can be regarded as an unselected sample of this entity in our area.

Corresponding author and reprint requests: Jose Luis Hernandez, Department of

Internal Medicine, Hospital Marques de Valdecilla, University of Cantabria,

39008 Santander, Spain

E-mail: [email protected]


Concise Communications 567

Data were obtained by a retrospective review of clinical charts

of patients with PHA, selected through the computerised data-

base of the Admissions andClinical Documentation Department.

PHA was defined on the evidence of one or more liver

collections without radiological characteristics of malignancy, in

US or CT studies, along with the identification of pus or

bacteria, either microscopically or by culture [5].

For the purposes of the study, patients were divided into two

different groups. Those patients in whom a diagnosis of PHA

was reached in the ER, constituted group A. Group B con-

tained those patients in whom PHA was not detected in the ER

evaluation.

The median follow-up of patients was 12 months. Data on

recurrence and mortality were also collected. PHA-related

mortality included both mortality resulting directly from the

abscess and mortality from a treatment complication.

Continuous variables are expressed as mean � standard

deviation and are analysed using the Mann–Whitney test.

Pearson’s w2 test or Fisher exact test (when expected frequencies

were <5) were used to compare qualitative variables between

both groups. The level of significance was established at 5% for

all the calculations.

RESULTS

General features

There were 63 patients with PHA during the study period. Of

these, 11 (17.5%) were correctly diagnosed in the ER (group

A), and 52 (82.5%) were admitted without a specific diagnosis

(group B). The mean age at admission was 59.8� 16.5 years for

the whole sample. In group A, the mean age was 49.3�8.8 years, and in group B it was 61.9� 15.3 years (P¼ 0.03).

There were 26 patients older than 65 years. Of these, diag-

nosis was only suspected in two cases (7.7%). In the group of

patients younger than 65 years (37 cases), PHA was suspected in

nine patients (24.3%).

The ratios of males to females were 1.2 : 1.0 in the group of

patients with PHA diagnosed at ER (group A), and 1.7 : 1.0 in

group B. The mean duration of symptoms before ER evaluation

was 8.8� 8.2 days versus 12.6� 14.5 in groups A and B

respectively.

Presenting symptoms and physical examination

The chief complaint in the ER was fever; seven cases (63.3%) in

group A, and 41 (78.8%) in group B. Fever was noticed by 22 of

26 patients older than 65 years. Abdominal pain was reported

more frequently by group B patients (24 cases versus four in

group A). Chills were noticed by five patients (45.5%) in group

A, and by 17 (32.7%) individuals in group B.

During the physical examination, jaundice was noted in five

patients of group A (45.5%), and only in 11 (21.2%) of group B.

In group B, hepatomegaly was detected more frequently than in

group A (Table 1). No statistically significant difference was

detected between the groups, although there was a trend

towards a greater presence of jaundice at admission in group

A patients (P¼ 0.09).

Predisposing conditions

Table 2 shows the predisposing conditions found in both groups

of patients. A past medical history of orthotopic liver trans-

plantation (P¼ 0.001) or biliary tract disease (P¼ 0.05) favored

a diagnosis of PHA in the ER. Globally, antecedent hepato-

biliary disorders (including orthotopic liver transplantation),

lead to a higher index of suspicion in the ER clinicians

(P¼ 0.004). Some form of immunosuppression was detected

in five out of 11 patients in group A, and in seven out of 45 in

group B (P¼ 0.02). Other predisposing conditions found in our

patients were as follows: alcoholism (two cases); recent (in the

previous week) abdominal surgery (two patients); chronic

brucellosis (one case); steroidal and immunosuppressive therapy

(one patient with rheumatoid arthritis and one case of systemic

vasculitis, respectively).

Radiological findings

A radiograph of the chest showed a greater number of pati-

ents with laminar atelectasis (P¼ 0.09), and pleural effusion

Table 1 Main clinical manifestations and physical examination findings of

the patients

FeaturesGroup An (%)

Group Bn (%)

Fever 7 (63.3) 41 (78.8)

Abdominal pain 4 (36.4) 24 (46.2)

Chills 5 (45.5) 17 (32.7)

Asthenia 4 (36.4) 14 (26.9)

Anorexia 2 (18.2) 12 (23.1)

Weight loss 2 (18.2) 11 (21.2)

Ascites ^ 2 (3.8)

Jaundice 5 (45.5) 11 (21.2)

Hepatomegaly 2 (18.2) 11 (21.2)

Table 2 Main predisposing conditions of patients with PHA

Predisposingconditions

Group An (%)

Group Bn (%) P value

HIV infection ^ 5 (9.6) NS

Liver transplant recipient 5 (45.5) 2 (3.8) 0.001

Biliary tract disease 5 (45.5) 9 (17.3) 0.05

Concomitant neoplasma ^ 5 (9.6) NS

Diabetes mellitus ^ 9 (17.3) NS

aCholangiocarcinoma (three cases), colorectal neoplasms (two patients).

HIV, human immunodeficiency virus; NS, not significant.



(P¼ 0.1) in group A than in group B (see Table 3). Globally,

radiological alterations (atelectasis, pleural effusion, or elevated

right hemidiaphragm) on plain chest films were more frequent

in the patients correctly diagnosed in the ER (P¼ 0.05).

Abdominal US was performed in all the cases diagnosed in

the ER (Figure 1). PHA were multiple in five cases (45.5%) of

group A (Figure 2), and in 25 (48.1%) of group B patients. In

group A, there was one case (9.1%) of concomitant splenic

abscesses, and six of these cases (11.5%) in group B. Ascites

was demonstrated in two patients in each group (18.2% versus

3.8%, P< 0.001) using US, but it was clinically detected only

in group B patients (both with a previous diagnosis of

cholangiocarcinoma).

Laboratory parameters

No difference was found in the hematological values or in the

liver function tests of both groups of patients. Only a trend

towards a greater increase of the erythrocyte sedimentation rate

was noted in the group A patients in comparison to group B (84

versus 60 mm/h; P ¼ 0.07).

Microbiological data

The causative micro-organisms did not differ between the

groups; enteric Gram-negative bacilli being the most frequently

isolated. Table 4 shows the main microbiological data of the

whole sample.

Outcome

The length of stay of group A patients was 45.0� 50.4 days, and

34.3� 22.1 days in the group B. There were two cases of

recurrent PHA in the group of patients diagnosed in the ER,

and seven in group B. Two out of 11 patients (18.2%) in group

A, and seven out of 52 (13.5%) patients in group B, died.

DISCUSSION

Based upon the lack of specificity of clinical symptoms and

signs, as well as laboratory parameters, diagnosing PHA remains

a difficult task for the clinician. This is particularly important in

the ER, since the time for a patient’s evaluation is often limited.

A diagnosis of suspicion of PHA was made in the ER in

nearly one-sixth of our patients. The patients correctly diag-

nosed at admission were younger than the patients undiagnosed.

Thus, in this study, age was an important clue when deciding to

request an US examination in patients suspectedof having a PHA.

PHA was traditionally considered as a subacute entity, with a

median of symptom duration before admission of over 2 weeks

Table 3 Chest X-ray findings in both groups of patients

Radiographof the chest

Group An (%)

Group Bn (%)

Atelectasis 3 (27.3) 4 (7.7)

Pleural effusion 6 (54.5) 15 (28.8)

Elevated right hemidiaphragm 1 (9.1) 5 (9.6)

Figure 1 Abdominal ultrasonography showing a large and heterogeneous

hepatic collection.

Figure 2 Contrast enhanced CT-scan showing two multiloculated hepatic

abscesses affecting both lobes.

Table 4 Microbiological findings in the whole sample

Micro-organismgroup n (%)

Most frequentspecies (n)

Gramnegative 22 (34.9) Escherichia coli (8)

Klebsiella pneumoniae (7)

Grampositive 11 (17.5) Enteroccoccus faecalis (4)

Viridans streptococci (3)

Anaerobes 5 (7.9) Prevotella spp. (2)

Bacteroides fragilis (1)

None 25 (39.7)


Concise Communications 569

[8]. However, in our series the median duration of symptoms

prior to ER evaluation was 9 days in the group A patients. It has

been suggested that the underlying condition may influence the

presentation in an individual patient [9]. In our study this may

be explained, at least in part, by the greater presence of liver

transplantation recipients in group A. The presence of fever or

abdominal pain in these patients, probably leads to a prompt

medical consultation.

A past medical history of orthotopic liver transplantation or

biliary tract disorders, also led to a higher index of suspicion by

the ER clinicians. In fact, 10 out of 11 patients correctly

diagnosed had one of these conditions.

The combination of fever and right upper quadrant pain,

classically associated with PHA, was only found in 19 (30.1%)

patients in our series, reflecting the non-specific nature of

clinical presentation in many cases, and the difficulty of an

early diagnosis [10].

Physical examination data were not helpful for the physicians

in the ER in most of the cases. In this regard, a classical sign such

as jaundice was present in only one-quarter of our cases.

However, it was the only feature that led to a more accurate

diagnosis (45.5% of group A vesrus 21.2% of group B), although

its importance did not reach statistical significance in our study,

probably due to the size of the sample.

Chest radiographs showed laminar atelectasis in nearly one-

third of the group A patients, associated with right pleural

effusion in half of them. These findings are consistent with those

previously published in the literature [10]. In the setting of a

patient with a clinical suspicion of PHA, these chest X-ray abnor-

malities probably reinforced the diagnosis, as our study suggest.

At admission, the presence of multiple abscesses in the US

study did not correlate with a more accurate diagnosis, although

they were more frequently detected in immunosuppressed

patients, as the literature states [8,10]. According to the chest

X-ray findings, there were no differences in the accuracy of the

diagnosis of suspicion between the groups, although radio-

graphic abnormalities were more frequent in the group with

multiple PHA, particularly laminar atelectasis and pleural effu-

sion. The higher rate of immunosuppression added to the fact

that hematogenous spread was predominant in this group, may

explain the remarkable incidence of splenic abscesses in these

patients.

Laboratory parameters were not helpful to the ER clinicians

to increase their index of suspicion for PHA. Retrospectively,

causative micro-organisms were not different between both

groups, and no severity patterns could be related to the etio-

logical agent at admission.

There was no association between a correct diagnosis in the

ER and the length of stay, nor with the rates of recurrence or

mortality. The most important determinant of mortality in our

patients, appeared to be the presence of severe underlying

diseases, as Seeto and Rockey have already pointed out [5].

In this regard, we found a higher rate of immunosuppressed

patients in group A, which could certainly affect the length of

stay and the prognosis in our series.

The two main limitations of our study are the size of the

sample and its retrospective nature. However, in the case of

PHA, large and prospective studies are lacking and, to our

knowledge, none of them are focused on the accuracy of

diagnosis in the ER.

In summary, diagnosing PHA in the ER remains a challen-

ging problem for the clinician owing to the paucity of the

symptoms and signs. In this study, we have found a subgroup of

patients with a high index of suspicion for PHA at admission;

younger, immunosuppressed, and with a past medical history of

biliary tree disorders. Conversely, an early diagnosis was a

difficult task in elderly patients.

Therefore, the first evaluation of an occult liver abscess may

be improved by a history directed to identification predisposing

conditions, mainly immunosuppression and hepatobiliary dis-

orders. The presence of right atelectasis or pleural effusion in

the chest radiograph could reinforce this suspicion in most of

the patients, even in the absence of the classical clinical features.

In these cases, an abdominal US or CT study would be strongly

advised.

ACKNOWLEDGMENTS

Part of this work was present at the XXV World Congress of

Internal Medicine in Cancun, Mexico, June 2000.

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Pyogenic hepatic abscess: clues for diagnosis in the emergency room