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 6-year-old malnourished boy was referred with a history of fever of 1-month duration, pain in right upper abdomen, loose motions, and vomitings for 14 days. The prior medical history was unremarkable. The physical examination revealed tachycardia and tachypnea. There was hepatomegaly with tenderness and guarding in the upper abdomen with ascites. On chest auscultation, the air entry was diminished on left side. Blood investigations are tabulated in . The chest radiograph showed left pleural effusion. An ultrasound showed a large single abscess of 94 ml in the left lobe of liver closely abutting the intra-hepatic vena cava. An echogenic lesion of 27 mm length extended from abscess to the IVC. Ascites was also noted. Contrast-enhanced computed tomography of abdomen revealed left lobe liver abscess in segments II and III. The thrombus was visible in the middle and left hepatic veins together with a thrombus in the IVC which extended up to the right atrium [].\nTwo-dimensional-echocardiography confirmed the above findings. The patient tested positive for amebic antibody by Enzyme-linked immunosorbent assay (ELISA) test. Broad spectrum antibiotics including metronidazole had been started by the referring institute. The patient was taken up for surgical intervention on an emergency basis. Median sternotomy and vertical pericardiotomy were performed. Cardiopulmonary bypass was established with aortocaval cannulation. After cooling to 20°C, cardioplegic arrest was achieved with root cold blood cardioplegia. Total circulatory arrest was established. Right atrium was opened parallel to the atrio-ventricular groove. Piecemeal extraction of the thrombus was done [].\nThe IVC was thoroughly irrigated with normal saline. The circulation was temporarily restarted to flush any small remnant thrombus in the IVC. The right atrium was closed and circulation was restarted. Trans-esophageal echocardiography confirmed complete removal of thrombus. Cardiopulmonary bypass was weaned off after re-warming. Left pleural cavity was drained with a tube. After reversal of systemic heparinization, the abdomen was opened by a roof top incision and the falciform ligament was divided. The left triangular ligament was divided to mobilize the left lobe. The abscess was palpable in the postero-superior aspect of segment II lying just left of the divided falciform ligament. It was adhered to the diaphragm which was dissected free and then the abscess was de-roofed. About 100 ml of anchovy sauce pus was drained from the abscess cavity. Lavage was performed followed by placement of tube drain in left sub-diaphragmatic space. Pus was sent for examination which failed to reveal any trophozoites on microscopic examination and was negative for pyogenic organisms. The patient was discharged on 10th post-operative day. The patient is on regular follow-up and he is in good health at 6 months from the date of operation.