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.
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.