A 21-year old male presented with upper abdominal pain for 15 days accompanied by a gradually increasing abdominal girth and swelling of the feet with low grade fever for one week. On examination, he was normo-tensive and showed pitting pedal edema. There was a tender hepatomegaly extending three fingers below the costal margin in the mid-clavicular line. Shifting dullness was positive. Hematological investigations revealed Hb level of 9 g/dL and WBC of 7,500/mm3. The biochemical investigations showed a raised BUN of 65 mg/dL and serum creatinine of 1.5 mg/dL. Urine analysis revealed slight proteinuria. Liver functions tests showed a total bilirubin of 0.6 mg/dL, serum ALP of 247 IU/L, AST 40 IU/L and ALT 80 IU/L. Ultrasonography of the abdomen showed an abscess in the right lobe of liver on its postero-superior surface measuring 1.4×1×1 cm with internal echoes and moderate ascites. Color doppler scan was done which showed patent hepatic veins with normal hepatofugal flow. Hepatic IVC was seen displaced and compressed by the large abscess cavity but the flow was normal. Infra-hepatic IVC was dilated to 1.7 cm. The Doppler findings were suggestive of IVC obstruction due to the liver abscess with proximal dilatation. A contrast enhanced CT scan confirmed the findings of thrombus in the IVC (). The patient tested positive for amoebic antibody by indirect haemagglutination test. The patient was started on intravenous metronidazole and broad spectrum antibiotics. The liver abscess was aspirated twice under ultrasonic guidance within a period of two days yielding 500 mL and 360 mL of pus. The pus was thick, creamy and brownish in color and did not grow any organisms on culture. The ascites and pedal edema disappeared rapidly after the treatment. Doppler scan repeated four days later showed a decrease in the infra-hepatic IVC dilatation. Hepatic portion of the IVC was normal in caliber and fully patent in subsequent color doppler examination performed twelve days after the aspiration of pus. The biochemical renal parameters improved and two weeks after aspiration of the liver abscess, the BUN was 32 mg/dL and serum creatinine was 1.1 mg/dL. Patient was followed up for three months, and repeat ultrasonography done was essentially normal.
We present the case of a 43-year-old West African male with a past medical history of untreated hepatitis B and chronic alcohol abuse. He complained of a one-week history of fever, chills, and worsening right upper quadrant abdominal pain with nausea and nonbloody, billous vomiting. The pain was described as being dull in nature, nonradiating, exacerbated by deep inspiration, and 8/10 in severity on the numeric rating scale. He also mentioned having a progressive and persistent nonproductive cough of the same duration. These symptoms began three weeks after he returned from a one-month vacation in West Africa.\nOn presentation, he was febrile with a temperature of 100.8 F, his heart rate was 108 beats per minute and he had tachypnea of 25 breaths per minute. Physical examination of the abdomen was significant for a persistent diffuse abdominal pain, most pronounced in the right hypochondrium, which hindered effective palpation of the liver borders. Exam of the thorax was significant for rapid shallow breathing with resultant decreased breath sounds diffusely, most pronounced over the right lung base. Hematological investigation was significant for a WBC of 30,500/μL (4500–11000/μL) with 80% polymorphonuclear leukocyte count (57–67%). AST/ALT was mildly elevated at 70/51 U/L (7–40 U/L) with an albumin of 2.7 g/dL (3.5–5.5 g/dL) and mildly elevated prothrombin time and INR of 15.4 s (11–15 s) and 1.42 s (0.8–1.2 s), respectively. Additionally, his PTT was also elevated at 36.7 s (20–35 s) and his D-dimer was elevated at 5.7 mg/L (0.2–0.7 mg/L). Of note, the bilirubin and creatinine were within normal limits.\nDue to positive D-dimer, tachypnea, tachycardia, and high suspicion of pulmonary embolism (Wells score of 4.5), given recent long distance travel, CT scans of the chest and abdomen with contrast were done. It found multiple left lower lobe subsegmental, right lower lobe, and right upper lobe segmental pulmonary emboli. There were also four small, scattered nonspecific pulmonary nodules. There was a 7 mm noncalcified lateral anterior right upper lobe nodule. There were pleural-based anterior bilateral upper lobe noncalcified nodules measuring up to 4 mm on the right and there was also a 3 mm lateral basal right lower lobe noncalcified nodule as well as a posterior left apical pleural-based 3 mm noncalcified nodule (). Also discovered were thrombosis of the hepatic portion of the IVC and left hepatic vein () and a large, irregular, heterogeneous marginated mass in the left hepatic lobe with a complex appearance and extensive enhancing septa, measuring approximately 8.5 × 9.6 × 6.8 cm. This appearance was highly suggestive of an abscess in the presence of concurrent CT evidence of colitis (). Transthoracic echocardiogram was only significant for moderate tricuspid regurgitation with a pulmonary arterial pressure of 39 mmHg but it was negative for intracardiac thromboembolism.\nAt this time, amebic liver abscess was the leading differential; hence, he was admitted and started on metronidazole 500 mg intravenously every eight hours along with warfarin bridged with unfractionated heparin for pulmonary emboli.\nHe remained hospitalized for twelve days, during which time serum antibody for Entameba histolytica was positive (confirming diagnosis) and AFP and CEA were found to be within normal limits ruling out possible malignancy. Work-up for underlying hypercoagulable states including factor V leiden, protein C, and protein S were all within normal limits and lower extremity duplex scan found no evidence of deep vein thrombosis. Since the clinical picture was highly suggestive for ALA and the patient was responding well, we believed further confirmatory test were unnecessary as it would not have changed our management. He finished a ten-day course of metronidazole with gradual amelioration of his fever, abdominal pain, and normalization of liver enzymes. He was subsequently discharged on paromomycin for seven days and continued on warfarin to follow as an outpatient.