Page 165 - Medical Parasitology_ A Textbook ( PDFDrive )

158 14 Case Reports

Source: Ng, Khuen Foong, Kah Kee Tan, Romano Ngui, Yvonne AL Lim,
Amirah Amir, Yamuna Rajoo, Hamimah Hassan, and Rohela Mahmud. “Fatal
case of amoebic liver abscess in a child.” Asian Pacific Journal of Tropical
Medicine 8, no. 10 (2015): 878–80.

Learning Points
1. Lack of suspicion of an amoebic liver abscess leads to a delay in treatment which
can be fatal.
2. Aspirated ‘anchovy sauce’ coloured pus is strongly suggestive of amoebic liver
abscess which should prompt the attending clinician to start treatment with
metronidazole.

Case 2: Gigantic Amoebic Liver Abscess in Pregnancy
Case report: A 29-year-old pregnant woman gravida 6 para 4 + 1 at 30-weeks gesta-
tion came to the hospital complaining of 4 days of fever, lethargy and flu like symp-
toms. There were no known comorbidities. She was initially given a course of
amoxicillin by her General Practitioner but to no avail and was subsequently admitted
to the hospital where she was suspected to have pneumonia. She appeared pale, mildly
tachypneic with a blood pressure of 107/63 mmHg, heart rate of 120–140 bpm, tem-
perature of 37.5 °C and a SpO 2 of 98% on nasal prong 2 L/min. Examination of her
cardiovascular system was unremarkable. Respiratory examination revealed mild
bibasal fine inspiratory crepitations which were attributed to over-hydration.
Abdominal examination revealed mild upper abdominal tenderness. Organomegaly
was difficult to appreciate in view of the gravid uterus. Laboratory investigations
showed an elevated ESR at 140 mm/h, total white count of 30–40 × 10 /L, elevated
9
alkaline phosphatase at 346 IU/L with borderline increment in alanine transaminase at
40–50 IU/L, raised lactate dehydrogenase at 1200–1300 IU/L with persistently low
albumin at 18 g/L. Bilirubin was normal. Her blood cultures, tuberculosis workup and
viral hepatitis were negative. Likewise, her transthoracic echocardiography was nor-
mal while her chest X-ray revealed interstitial edema in keeping with the clinical find-
ings of over-hydration. An abdominal ultrasonography revealed a huge nonliquefied
abscess at the right lobe of liver measuring 13.6 cm × 15.9 cm × 20.2 cm in dimen-
sion. Antibiotics were changed to intravenous meropenem 500 mg 8 hourly alongside
intravenous metronidazole 500 mg 8 hourly to cover for potential pyogenic and amoe-
bic liver abscess. Further history revealed factors of poor personal hygiene and sanita-
tion coupled with overcrowded living conditions. There was no history of dysentery,
no suggestion of immunosuppression and her HIV screen was negative. Her travel
history was insignificant. Ultrasound guided percutaneous liver abscess drainage was
done upon transfer to a subspecialized tertiary centre in which 2.3 L of odourless
brownish pus (anchovy sauce pus) was drained over time. This was tested to be posi-
tive for Entamoeba histolytica by PCR. She completed 2 weeks of intravenous metro-
nidazole with no untoward complications and the pregnancy progressed normally to
term, when she delivered a healthy baby girl. Repeated ultrasonography showed pro-
gressive size reduction of the liver abscess cavity.