|Year : 2019 | Volume
| Issue : 2 | Page : 53-56
Amoebic liver abscess in an infant
John Sheyin1, Joseph Bako Igashi2
1 Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Zaria, Kaduna, Nigeria
2 Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Ahmadu Bello University, Zaria, Kaduna, Nigeria
|Date of Submission||19-Nov-2019|
|Date of Acceptance||26-Mar-2020|
|Date of Web Publication||08-Aug-2020|
Dr. John Sheyin
Department of Radiology, Faculty of Clinical Sciences College of Medicine, Kaduna State University, Kaduna
Source of Support: None, Conflict of Interest: None
Amoebic liver abscess (ALA) is the most common inflammatory space occupying lesion of the liver in human. It is considered the third leading cause of death among the parasitic diseases, surpassed only by malaria and schistosomiasis. It has a highly variable presentation causing diagnostic difficulties. ALA if untreated, its complications could lead to high morbidity and mortality. We present a 1 year old child with abdominal pain and distension, persistent fever and weight loss. The abdomen was distended with tenderness on the epigastric and right hypochondrial regions. Hematological and biochemical profile were normal. Abdominal CT showed hepatomegaly, with a huge hypodense mass within the liver with enhancement of the liver parenchymal on contrast injection. There was breach of the hepatic capsule with localized intraperitoneal collection. A diagnosis of pyogenic liver abscess was made. Attempt to aspirate under US guide was unsuccessful. Patient underwent surgery and 500 ml of pus was drained.
Keywords: Amoebic liver abscess, entamoeba histolytica, liver radiodiagnosis
|How to cite this article:|
Sheyin J, Igashi JB. Amoebic liver abscess in an infant. Arch Int Surg 2019;9:53-6
| Introduction|| |
Liver is the most common site of extraintestinal amoebiasis.,,,,,,, Amoebic liver abscess (ALA) is a common clinical problem in developing countries.,,,,,, The causative agent is a protozoan, entamoeba histolytic.,,,,, It is prevalent mainly among the lower socioeconomic class living in unhygienic conditions. ALA is common in particularly in male adults.,, It carries a significant morbidity and mortality even in this modern era, especially in pediatric age group.,, ALA could present with protean manifestations, especially when the index of suspicion is low. Such uncommon manifestations are due to complications which result from rupture of the abscess into adjacent cavities such as pleural, pericardium, peritoneum, retroperitoneal or compression of the tubular structures in the hepatic hilum or distant embolic dissemination to the brain and spleen.,,,
Amoebic abscess could be diagnosed based on a serology test such as indirect fluorescent antibody test or demonstration of entamoeba histolytica trophozoites in aspirated pus. Detection or diagnosis of ALA or it complications can remain elusive for weeks or months with obvious worsening prognosis. New modalities of cross sectional 3D imaging including computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound (US) have come to the rescue in ensuring early diagnosis. It affects mostly the right lobe and it is also the commonest lesion that affects the left lobe in tropical countries., It enters the liver via bilary tract, portal vein, hepatic artery, direct extension from contiguous organs or by trauma.,,,
Male are affected more than female and mainly the younger one.,, It is uncommon in infants, but it is a significant cause of morbidity in children in the developing world.,, It has been suggested that the overall incidence in adults is increasing because of a wider availability of diagnostic procedures. The mortality rate however has improved because of better methods of it management. We present the management and radiological evaluation of an infant with ALA.
| A Case Report|| |
I A is a 1 year male child who was referred from a private hospital in Bauchi town of Nigeria to the Pediatrics Department of Ahmadu Bello University Teaching Hospital (ABUTH), Zaria with a history of abdominal pain and distension, persistent fever and weight loss.
On examination, acute ill looking child, irritable, feverish, anicteric, not dehydrated and no pedal oedema. The abdomen was distended more on the right side and with tenderness on the epigastric and right hypochondrial regions. There was hepatomegaly of 8 cm below costal margin. Other systems were essentially normal. A differential diagnosis included typhoid septicemia, hepatoblastoma, liver abscess and viral hepatitis were made.
The hematological profile and U and E and creatinine were normal. The chest radiograph showed elevation of the right hemidiaphragm [Figure 1]. The first abdominal ultrasound showed hepatomegaly. Within the liver was a huge complex lesion (mass) in the right lobe which measured 7.6 × 6.9 × 6.8 cm in dimensions. It was initially solid with mixed echogenicity and a diagnosis of hepatoblastoma was made to rule out chronic liver disease.
|Figure 1: Chest x-ray (pa view) showing elevation of the right hemidiaphragm|
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Second ultrasound was done after one week interval and the findings were similar to the first one. A repeat third US was done 3 days after the second one, the findings were still the same. A fourth US was done (after CT was done) and it showed a hypoechoic lesion in the right lobe of the liver [Figure 2].
|Figure 2: Ultrasound (sagittal view) showing hypoechoic collection in the liver|
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The axial CT [Figure 3] and [Figure 4] showed hepatomegaly, with a huge complex mass within the liver which was hypodense, with enhancement of the liver parenchymal on contrast medium injection. There was breach of the hepatic capsule with localized intraperitoneal collection. A diagnosis of pyogenic liver abscess was made. An attempt was made twice to aspirate under US guide but it was unsuccessful. Patient underwent surgery and about 500 ml of pus was drained. A drainage tube was left insitu, which was removed after it became dried.
|Figure 3: Axial CT image of the abdomen with oral contrast showing a hypodense lesion in the liver|
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|Figure 4: Axial enhanced (iv and oral) ct image of the abdomen showing hypodense lesion in the liver with a defect of the liver capsule|
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The pus was sent for microscopy, culture and sensitivity (m/c/s) and Entamoeba histolytica was isolated. Patient was then placed on antibiotics (metronidazole) for three weeks. Patient recovered and was discharged home, to be seen in the clinic which he attended four times with no new complaint. He was then discharged from the clinic.
| Discussion|| |
Liver abscess is rare in the developed countries but common in developing countries. There is a male preponderance in reported cases.,,, This patient was a male. Amoebic liver abscess is seen mostly in patient who are in an endemic areas or those who have visited endemic areas and rarely in those who are not exposed to the above conditions. The causative organism is Entamoeba histolytica. This patient was from Bauchi town, a reported endemic area in Bauchi State, Nigeria and the father was a lecturer in a tertiary educational institution (social status is middle class) who had other five children. The mother was a house wife.
It is common in adults and rare in infants. In this case, it was a one year old child. Children have a unique set of predisposing factors for developing liver abscess including parasitic infestations, genetic disorders, skin infections, protein calorie malnutrition (PEM), abdominal pathology including choledochal1 cysts, congenital hepatic fibrosis and post-traumatic both by direct injury to the liver or by providing a habitat for proliferation of organisms elsewhere. The predisposing factor in this patient was unknown.
The most frequent symptoms of hepatic abscess include fever (either continuous or spiking), right upper quadrant pain, malaise, anorexia and weight loss,,,,, all of which this patient had. The physical examination findings were most notable right upper quadrant tenderness which the patient had. Hepatomegaly which was also applicable in this case, with or without palpable mass and jaundice are also common and not seen in this case. Jaundice which may be present in 25% of cases is usually associated with biliary tract disease or the presence of multiple abscess. Patients may present with pulmonary complications such as rales, pleural effusion, friction rub, pulmonary consolidation or pulmonary abscess,, not seen in this case.
If the morbidity and mortality from liver abscess is to be kept as low as possible, early diagnosis is essential. Although there are clinical features that may suggest liver abscess, the definitive diagnosis is made by ultrasound and computed tomography and microscopy,, which the patient had. Due to variations in appearance of the lesion (abscess) with time. The diagnosis by ultrasound or computed tomography could be difficult due to the diversity in it appearance with time. It appearance on CT and ultrasound depends mainly on the chronicity of the abscess. This patient also had this problem of diagnosis. Acute lesions often appear solid or relatively solid and with time the appearance change to fluid. Due to this variation in it appearances (this patient had this), the differential diagnosis include the following: hepatic cyst, hydatid cyst, cystic and solid tumors and hematoma. It is usually the presence of the fever that may suggest to the radiologist that the diagnosis is likely to be liver abscess.
Radionuclear imaging was used in the past, which has given way to computed tomography scan. Recently, magnetic resonance imaging has been used to characterize liver abscess, which the patient did not have due to the fact it is expensive and the strength of the magnet is low (0.2 tesla). MRI usually show a ringed lesion within the liver, which may be incomplete and of variable intensity, better seen on T1 than on T2 weighted image. It may be hyperintense on T1. However, during antibiotic treatment, T1 and T2 weighted images showed the development on four concentric zones because of central liquefaction and resolution.
Treatment included conservative management, in which the patient was managed with antibiotics. Surgical treatment included percutaneous catheter drainage, which was attempted in this patient but it failed. The procedure has several advantages and can be accomplished under ultrasound or computed tomography control. It helps to confirm the diagnosis through microscopy, culture and sensitivity of the pus as in this case. It gives a better bacteriological yield 82% compared to 47% from blood culture. It gives an equally good outcome to surgical drainage and has less procedure related morbidity. Finally, unsuspected underlying conditions may be diagnosed from aspirated material.
Laparotomy is done when percutaneous drainage failed or when there are complications. Our patient had laparotomy and drainage of the pus afterb several attempts at percutaneous drainage failed. The pus was sent for Microscopy, culture and sensitivity and Entamoeba histolytica were isolated.
Radiological investigations play a significant role in the diagnosis of ALA. Once the diagnosis is established, it can be successfully treated by image guided percutaneous aspiration the failure of which can be followed by laparotomy and drainage.
| Summary|| |
A case of amoebic liver abscess in an infant, the clinical features, radiological investigations and literature review were discussed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]