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.
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.