Intrahepatic Administration of Liposomal Amphotericin B for the Management of a Candida Albicans Liver Abscess in a Preterm Neonate

Introduction: No data exist about the direct intrahepatic administration of amphotericin B liposomal neither in adults nor in children to treat liver fungal abscesses. In adults, intraportal administration of amphotericin B has been only occasionally described. We report the management of a Candida albicans liver abscess successfully treated with intrahepatic administration of liposomal amphotericin B in a neonate born preterm, with systemic candidiasis.

Materials and Methods: A 14-day, preterm neonate (gestational age: 28 weeks, birth weight: 1,000 g), with an intrahepatic, ovalar, cystic, tender mass, due to parenteral nutrition extravasation through the umbilical venous catheter, was referred to our neonatal intensive care unit. At admission, ultrasound (US) and abdominal computed tomography (CT) scan, the mass (d = 65 × 45 × 35 mm) appeared multilobulate, with a dishomogeneous, colliquative core, placed in the right hepatic lobe (IV segment) with dislocation of hepatic vessels and gallbladder ([Fig. 1A], [B]). On admission, the neonate was ventilated and assisted with inotropes. A two-lumen central venous catheter (CVC) through the left jugular vein was placed. On day of life (DOL) 18, peripheral and CVC blood cultures turned positive for C. albicans and intravenous micafungin (Mycamine, 8 mg/kg/die) was started, without clinical improvement. Despite the Candida strain was susceptible to micafungin (MIC 0.015 µg/mL) and blood concentrations of Mycamine were within the therapeutic ranges,¹ that is, 3.1, 18.0, 16.0, and 10.4 µg/mL 1 hour before and 1, 2, and 8 hours after infusion, peripheral and CVC blood cultures continued to be positive after 14 days of antifungal therapy. Intravenous amphotericin B liposomal (ambisome, 3–5 mg/kg/die) was therefore associated to micafungin, the lock therapy of the CVC with Mycamine (5 mg/mL, 12 hours into each lumen)² was started and the CVC was replaced. On DOL 35, due to both persistently positivity of blood cultures for C. albicans and the increasing amount of ascitic fluid, suspecting Candida infection of the preexisting hepatic lesion, an intrahepatic drainage was placed. As expected, Candida grew up from the fluid. Therefore, daily administration of 10 mL of Ambisome (5 mg/L, in isotonic water) through such drainage was performed. One week later, blood and intrahepatic fluid cultures were finally negative for yeasts and neonate’s conditions progressively improved. The intrahepatic lesion appeared markedly reduced at the following hepatic US assessment (d = 3 cm).^3–5

Conclusion: According to our experience, this therapeutic approach was safe and allowed the resolution of a critical life-threatening situation which had not responded to any other intensive treatment. Further investigations are required to confirm such results ([Fig. 1]). US ([Fig. 1A]) and CT ([Fig. 1B]) imaging showing an intrahepatic lesion involving the right lobe; X-ray imaging showing left peritoneal catheter and intrahepatic drainage ([Fig. 1C]).

Keywords: Candida albicans, liver abscess, neonatal candidiasis, antifungal drugs resistance

Fig. 1 (A-C) Ultrasound and computed tomography scans.