A case of frank amoebic liver abscess reported in NEJM

A case of frank amoebic liver abscess reported in NEJM.This case has been reported by Dr Hsin-Hui Wang at Kaohsiung Medical University Hospital, Kaohsiung, Taiwan and colleagues.

Amebic liver abscess is the most frequent extraintestinal manifestation of Entamoeba histolytica infection. This infection is caused by the protozoa E histolytica, which enters the portal venous system from the colon. Amebic liver abscess is an important cause of space-occupying lesions of the liver, mainly in developing countries. An estimated 4% of patients with amebic colitis develop an amebic liver abscess.

A 29-year-old man infected with the HIV presented to the emergency department with a 2-day history of fever and pain in the right upper quadrant of the abdomen. His most recent CD4 cell count was 520 per microliter. Laboratory results showed an aspartate aminotransferase level of 208 IU per liter (reference range, 10 to 42), an alanine aminotransferase level of 467 IU per liter, and a total bilirubin level of 2.4 mg per deciliter (reference range, 0.2 to 1.0).

Courtesy NEJM
CT of the abdomen performed after the administration of contrast material revealed a ring-enhancing lesion in the liver that was suggestive of an abscess (Panel A). A reddish-brown material was obtained on percutaneous drainage of the abscess (Panel B). Microscopic examination revealed unicellular organisms with pseudopods (Panel C).

An indirect hemagglutination test for antiamebic antibodies was positive, at a titer of 1:256. A polymerase-chain-reaction assay of stool confirmed infection with Entamoeba histolytica. E. histolytica infections result from the ingestion of amebic cysts. Contaminated food or water is typically the source.

Metronidazole was administered for 2 weeks and was followed by 10 days of treatment with paromomycin to eliminate intracolonic cysts. The patient’s fever and abdominal pain subsided 2 days after the initiation of treatment, and the liver abscess had decreased in size on follow-up abdominal ultrasonography. At a 90-day follow-up visit, the patient had no further symptoms.

Control of amebiasis can lead to less number of cases of amoebic hepatitis and liver abscess which be achieved by exercising proper sanitary measures and avoiding fecally contaminated food and water, including the following:

• 
  
  
  
  Regular examination of food handlers and thorough investigation of diarrheal episodes may identify the source of infection in some communities.
  
  


• 
  
  
  
  Vegetables must be cleaned with a strong detergent soap and soaked in acetic acid or vinegar for approximately 15 minutes to eradicate the cyst forms.
  
  


• 
  
  
  

  Boiling is the only effective means of eradicating the cysts in water.