A 26-year-old male presented with fever and upper abdominal pain for nine days. Two days prior to presentation, he had developed exertional chest pain and dyspnea. There was no history of diarrhea. He had no significant past medical, surgical and travel history, and there was no family history of thrombotic disorders. On presentation, he was febrile and had a tender abdomen. He had tachycardia with pulse rate of 110 per minute and blood pressure was 110/70 mm Hg. Pulse oximetry revealed capillary blood oxygen saturation of 94% while breathing room air.\nHis electrocardiogram was normal and chest radiograph revealed minimal pleural effusion on the right side. Blood investigations revealed an elevated white blood cell count of 17.5 x 109/L (normal range: 4-12 x 109/L) and mildly deranged liver functions with aspartate transaminase (AST) elevated to 69 U/L (normal range: 5-40 U/L), alanine transaminase (ALT) elevated to 71 U/L (normal range: 5-40 U/L) and alkaline phosphatase (ALP) elevated to 350 U/L (normal range: 30-140 U/L). On ultrasound scan of abdomen, the liver was found to be enlarged to 20 cm with a hypoechoic lesion in the right lobe (Figure ). The serologic diagnosis of ALA was confirmed with indirect hemagglutination. Contrast-enhanced computed tomographic (CT) scan of abdomen showed hepatomegaly with an abscess of 8.6 cm x 3.8 cm in segment VIII of the right lobe causing IVC compression with a thrombus inside its lumen (Figures , ). CT pulmonary angiogram revealed a filling defect in right lower lung segmental artery (Figure ). Echocardiography and venous Doppler of the legs did not reveal any abnormality.\nThe treatment comprised of intravenous metronidazole (800 mg thrice a day) along with the oral luminal amebicide agent, diloxanide furoate (500 mg thrice a day) for 10 days. Percutaneous needle aspiration of the abscess was carried out. Anticoagulation with weight-based dose of subcutaneous enoxaparin (60 mg twice a day) was simultaneously started and later bridged to warfarin to maintain international normalized ratio (INR) of 2-3. The patient became asymptomatic and anticoagulation was discontinued after three months.
A 24-year old man presented with pain in right upper abdomen with fever for five days. Physical examination revealed high grade fever and tachycardia. There was tenderness and guarding in right hypochondrium. There was bilateral pedal edema. Hematological investigations revealed a hemoglobin (Hb) level of 11.2 g/dL and white blood cell (WBC) count of 18,400/mm3 (normal range, 4,000-11,000/mm3). The biochemical investigations showed a blood urea nitrogen (BUN) of 34 mg/dL (normal range, 15-40 mg/dL), serum creatinine of 1.1 mg/dL (normal range, <1 mg/dL). Liver functions tests showed a total bilirubin of 1.5 mg/dL (normal range, <1 mg/dL), serum alkaline phosphatase (ALP) of 178 IU/L (normal range, 40-280 IU/L), aspartate aminotransferase (AST) 32 IU/L (normal range, <40 IU/L), alanine aminotransferase (ALT) 48 IU/L (normal range, <40 IU/L). Chest X-ray was normal. Ultrasound at admission showed a large (8.6×7.3×6.2 cm), volume 202 mL, heterogeneously hypoechoic lesion with internal echoes in the caudate lobe suggestive of liver abscess. On ultrasonography, the abscess was compressing the intra-hepatic IVC with abnormal color fill (slowed down) and flow pattern. Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) was performed which confirmed 6.9×6 cm abscess in the caudate lobe causing eccentric compression over the intrahepatic part of IVC (, ). There was a mass effect with compression of the main portal vein and the common hepatic duct just after the ductal confluence, however, the right and left hepatic ducts and intra-hepatic biliary radicals were not dilated. The patient tested positive for amoebic antibody by enzyme-linked immunosorbent assay (ELISA) test. The patient was started on broad spectrum antibiotics and metronidazole for two weeks. After initiating the treatment, there was a gradual amelioration in the fever and abdominal pain. Repeat ultrasound by the end of first week revealed a gradual reduction in the size of the abscess to 50% of its original size and the compression on IVC was also relieved as confirmed by doppler scan. The patient was asymptomatic. Follow-up investigations showed WBC of 8,800/mm3, and liver functions tests showed a total bilirubin of 0.5 mg/dL, serum ALP of 145 IU/L, AST 40 IU/L, ALT 45 IU/L. Patient was followed up for three months and repeat ultrasound done at the end of three months showed no residual abscess and IVC was normal in caliber, color fill and flow pattern.