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.
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.