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 61-year old man presented with high grade fever for eight days, vomiting for five days associated with right upper abdomen pain, yellowish discoloration of eyes for three days, and swelling of the feet for three days. He was icteric with a pulse rate of 96/min and blood pressure of 126/80 mmHg. There was bilateral pedal edema. On abdominal examination, tender hepatomegaly was present three finger breadth below the costal margin. Ultrasonography revealed multiple abscesses in the liver, the largest one 8×7.2×6.8 cm in the right lobe with mild pleural effusion. Hematological investigations revealed a Hb of 9.4 gm/dL and WBC 29,900/mm3 with predominantly polymorphic leukocytosis. The biochemical investigations showed a raised BUN of 59 mg/dL, serum creatinine of 1.2 mg/dL. Liver function tests showed total bilirubin of 4.9 mg/dL, direct bilirubin of 3.8 mg/dL, ALP of 1,055 IU/ L, AST of 99 IU/L and ALT of 108 IU/L. The patient tested positive for amoebic antibody by ELISA test. MRI with MRCP revealed four abscesses, two in the right lobe, one in the left lobe and one in the caudate lobe (). The largest one was 7.5×7.2×7 cm in size, in the right lobe. The abscess in the caudate lobe was compressing the porta hepatis and IVC (). The flow in IVC was found to be slowed down on color doppler. Catheter drainage was done from the largest abscess and the patient was started on intravenous metronidazole and broad spectrum antibiotics. Total 580 mL of pus was drained before the catheter was removed. After five days of admission the pedal edema reduced markedly and after ten days it subsided completely. Liver function tests returned to normal range with total bilirubin 1.1 mg/dL, direct bilirubin 0.3 mg/dL, ALP 22 IU/L, AST 42 IU/L and ALT 20 IU/L. The patient was discharged in good condition and 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.