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.
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.