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Twelve patients with amebic liver abscess were admitted to a university hospital. Ten of these patients were admitted through the emergency department. Patients, especially men from third world countries, with fever, right upper quadrant pain, and leukocytosis are at high risk for this disease and should have the diagnosis confirmed with amebic serology and ultrasonography or computed tomography.
A comparison has been made between scintigraphy with radioactive gold and selective angiography as methods of diagnosing amebic liver abscess in a small series begun in 1965. In 5 cases with a positive scintigraphy, the diagnosis of a liver abscess was supported by angiography in 3.
We reviewed 204 cases of liver abscess seen between 1970 and 1985. Ninety were found to be amoebic, 24 pyogenic and one tuberculous. The cause of the abscesses in the remaining 89 patients was not established. The patients were predominantly male, Indians, and in the 30-60 age group. The majority of patients presented with fever and right hypochondrial pain. The most common laboratory findings were leucocytosis, hypoalbuminaemia and an elevated serum alkaline phosphatase. Amoebic abscesses were mainly solitary while pyogenic abscesses were mainly multiple. Complications were few in our patients and included rupture into the pleural and peritoneal cavities and septicaemic shock. An overall mortality of 2.9% was recorded. The difficulty in diagnosing the abscess type is highlighted. The single most important test in helping us diagnose amoebic abscess, presumably the most common type of abscess in the tropics, is the Entamoeba histolytica antibody assay. This test should be used more frequently in the tropics.
We report the case of a 51-year-old man with hepatic amebic abscess complicated by hepatic artery aneurysm. The patient first presented with peritonitis caused by perforating appendicitis. Surgical treatment resolved peritonitis but Entamoeba histolytica was detected in the colonic mucosa. Subsequently, liver abscess developed and the size of the abscess increased gradually after surgery in spite of continued treatment with metronidazole. Brown pus was drained from the abscess but 13 days after the drainage process the patient complained of right upper abdominal pain and the drained fluid became blood-colored and stool became tarry in color. Enhanced computed tomography showed a hepatic artery aneurysm that had ruptured into the liver abscess and duodenoscopy revealed bleeding from the ampulla of Vater. Transcatheter arterial embolization with several steel coils was successfully performed which resulted in cessation of bleeding from the ampulla of Vater. The patient was discharged without any complications five weeks after rupture of the aneurysm. Our case demonstrates rupture of the hepatic artery aneurysm as a rare complication of amebic liver abscess and the effectiveness of interventional embolotherapy in this condition.
Disseminated fungal infection not infrequently complicates the course of allogeneic bone marrow transplantation (allo BMT) in severely immunocompromised patients, and the prognosis of BMT patients who develop systemic fungal infection is very poor. We describe a patient who developed disseminated Candida albicans infection with liver abscess after the first allo BMT for acute myelogenous leukemia (FAB M2). The infection was successfully eradicated by the administration of miconazole and amphotericin B. However, 1 year after the first allo BMT, the patient suffered a relapse of acute myelogenous leukemia with fungal liver abscess. A second allo BMT, accelerating granulocyte recovery by recombinant human granulocyte colony-stimulating factor (rhG-CSF), was successfully performed and the fungal liver abscess resolved with a combination therapy of fluconazole and amphotericin B. The patient is alive and free of both leukemia and fungal disease more than 37 months after the first allo BMT and 25 months after the second allo BMT.
Immunization of hamsters by intramuscular injections of an amebic extract and of two of its fractions, emulsified with complete Freund's adjuvant, resulted in protection against the development of amebic liver abscess, following intrahepatic inoculation of axenic trophozoites of Entamoeba histolytica such that Fraction I, Fraction II, and the whole antigen conferred protection to 18 out of 18, 4 out of 18, and 11 out of 18 hamsters, respectively. Splenomegaly was found to accompany the development of hepatic liver abscesses in this experimental system. There was a very high degree of correlation (r = 0.95) between the weights of the abscesses and the spleens. On the other hand, there was no correlation between the anti-amebic antibody titers (determined by the indirect hemagglutination test) and the development of the liver abscesses within the time-span of the experimental protocol used in this study.
Achromobacter xylosoxidans is a microorganism that may cause opportunistic infections. We detected A. xylosoxidans in three of 46 patients with liver abscess. The clinicopathologic findings of the three patients were uniform with respect to a prior history of cholecystectomy, multi-lobulated 'coral-like' abscess under CT and epithelioid granulomas in the periphery of the abscess. Achromobacter xylosoxidans is an unrecognized cause of liver abscess in humans.
Amebic liver abscess (ALA) is uncommon in the United States and is potentially lethal when acquired during the first year of life. The clinical course of ALA in a 10-month-old infant is presented and the characteristics of 18 previously described cases of infants with ALA from the United States are reported; this infant population (including our patient) is compared with a population of adults with ALA. In contrast to the initial signs in adults, those in infants are nonspecific and include fever, hepatomegaly, anemia, and elevated levels of transaminases. Colitis may occur in infants, but results of examinations for ova or parasites are usually negative. On presentation the amebic serology for one-third of infants with ALA is negative. The clinical course of ALA in infants is usually fulminant and is associated with a mortality rate of nearly 50%.
Among patients presenting with pain and tenderness in the right upper quadrant were 75 with cholelithiasis (13 male, 2 under age 50) and 9 with amebic hepatic abscess (6 male, all under age 45). The differential diagnosis of cholelithiasis versus liver abscess was accurately made by prompt sonography and hepatobiliary scintigraphy. Amebic abscess was confirmed by positive serum ameba titers. Presenting symptoms and results of laboratory studies of patients with amebic abscess were indistinguishable from those of patients with cholecystitis. It is concluded that an accurate diagnosis of amebic liver abscess in the differential diagnosis of cholecystitis can be made by sonography and hepatobiliary imaging. Also, in endemic areas of the southwestern United States, amebic abscess should be strongly considered in the differential diagnosis of patients presenting with pain and tenderness in the right upper quadrant and is more common than cholecystitis in young men.
The study presented here was performed to evaluate the need for aspiration in patients with amebic liver abscess (ALA). Patients older than 12 years with a diagnosis of ALA based on clinical features, ultrasound results, and positive amebic serology were included in the study (n=144). Serological testing was performed to detect the presence of immunoglobin G antibody against Entamoeba histolytica, and a value of more than 0.4 optical density units was considered positive. All patients were given intravenous metronidazole (500 mg every 8 h) and their clinical progress and need for abscess aspiration was documented. Fever, pain in the upper abdomen, and tender hepatomegaly was seen in 133 (92.3%), 128 (88.8%), and 144 (100%) patients, respectively. Multiple abscesses were seen in 40 (27.7%) patients. Six (4.1%) patients died. Seventy-one (49.3%) patients responded to metronidazole alone. A total of 73 (50.69%) patients required aspiration of the abscess. This study shows that almost 50% of the patients with amebic liver abscess failed to respond to metronidazole and required aspiration.
Bacillus cereus is a food-borne pathogen that causes a self-limiting gastroenteritis. We describe the case of a 72-year-old woman admitted to our hospital because of acute abdominal colic pain. Over a 2-day period, her clinical condition deteriorated rapidly, with the appearance of acute abdomen. Computed tomography investigation of the abdomen showed a liver abscess (diameter approximately 3 cm). At laparotomy, the abscess was found to be ruptured to the free peritoneal cavity. The final clinical diagnosis was acute peritonitis due to a ruptured liver abscess. Bacillus cereus was isolated from culture of the pus. Up to now, no case of liver abscess due to this organism has been reported.
A total of 182 TAE procedures were carried out in 98 patients with malignant hepatic tumors during the last five years. Liver abscess following TAE occurred in 3 cases (3.1%) and in 3 procedures (1.7%). All cases were discharged after successful percutaneous transhepatic abscess drainage. One case had hepatocellular carcinoma. Another case had undergone total gastrectomy and esophagojejunostomy with Roux-Y reconstruction for gastric leiomyosarcoma. The other had undergone right hemicolectomy and pancreatoduodenectomy for colon cancers and carcinoma of the ampulla of Vater. Communication between the abscess and the intrahepatic bile duct was recognized in 2 cases. In the abscess culture, E. coli and Citrobacter freundii were detected. These results suggest the major factor leading to abscess formation is biliary infection. Therefore, a previous bilio-enteric anastomosis should be regarded as a risk factor for liver abscess following TAE.
The potential utility of Gd-DTPA contrast enhancement of MR images in the evaluation of liver abscesses was assessed in rodents. Twelve rats with surgically implanted sterile liver abscesses were imaged at various stages of focal hepatic inflammation, 48 hours, 4 days, 7 days, 14 days and 21 days after lesion induction. Spin echo images, acquired before and repeatedly after intravenous injection of 0.2 mmol/kg Gd-DTPA, demonstrated improvement of the lesion-to-background contrast ranging from 2% to 40% depending on the stage of the disease. The enhancement pattern also varied with abscess evolution. Two, four and seven-day-old abscesses typically showed a ring enhancement, whereas two- and three-week-old abscesses presented largely homogeneously enhancing lesions. In the earlier lesions, contrast enhanced rim surrounding the low intensity center corresponded histologically to the formation of a capsule consisting of fibrous tissue and inflammatory cells. The center was necrotic. Data show that abscesses can be detected on images acquired with long repetition and echo times without injection of Gd-DTPA. The administration of Gd-DTPA, however, improved the lesion-to-background contrast and helped to define the abscess capsule evolution.
A 45 year old woman presented with pain in her right upper abdomen and fever. Ultrasound of her abdomen showed a large liver abscess with subhepatic collection. She had Cullen's sign. The liver abscess was managed by percutaneous catheter drainage.
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Invasive amebiasis rarely occurs in homosexual men and human immunodeficiency virus (HIV)-infected individuals and has not been regarded as a beacon for concomitant HIV infection. We encountered a bisexual man with a protracted course of amebic liver abscess and amebic colitis. In the presence of fever, generalized lymphadenopathy, and elevated serum aminotransferase levels, HIV infection was suspected and then confirmed by a de novo seroconversion of HIV antibody. Subsequently, we noted two consecutive patients with amebic liver abscess, also later found to be infected with HIV. The ameba obtained from these three cases was identified as Entamoeba histolytica by amplification of 16S ribosomal RNA by polymerase chain reaction and direct sequencing. This observation suggests that amebic liver abscess and colitis can be presentations for HIV infection in the Far East. Thus, the local patients with invasive amebiasis, especially those with a protracted course or with risk factors of HIV infection, should be tested for HIV.
The association between parasitic diseases, and antigens of the major histocompatibility complex in man (HLA) has been poorly studied. The only study of the association between the HLA system and amebic abscess of the liver was performed by our group, and revealed a significant increase in HLA-BI6 and HLA-DR3 in patients with amebic abscess of the liver. The present study covered a larger number of patients and controls (110 of each) and it confirmed the association with HLA-DR3, it failed to confirm the association with HLA-BI6.
A forty-eight year-old man complained of upper abdominal pain and diarrhea with mucinous bloody stool. He had not been abroad. Except high fever, anemia, leukocytosis and elevated rate of erythrocyte sedimentation, laboratory findings were not abnormal. Gastrofiberscopy showed the protrusion of gastric mucosa with a hollow on its surface in the angle. Abdominal CT scan and echogram revealed an abscess in the right hepatic lobe and an abscess in the left lobe. Ulceration and small protrusion of the rectal mucosa were found by romanoscopy. Stool examinations could not reveal amebas, but serological test for amebiasis by the Ouchterlony method showed positive. Under the diagnosis of the perforation into the stomach of amebic liver abscess, he was treated with Metronidazole and tetracycline. But, as a diffuse shadow appeared in the right thoracic cavity on the chest x-ray films with bloody sputa, perforation of amebic liver abscess to the right thoracic cavity was suspected. Laparotomy showed the communication of the abscess to gastric lumen. The post operative course was uneventful. We reported a case with the rare complication of amebic liver abscess.