Amoebic liver abscess with metastatic amoebic brain abscess: A case report

Abstract

Background: Amoebic liver abscess may be single or multiple. It is mostly seen in tropical areas. Aims: Amoebic liver abscess may rupture into pleura, pericardium, peritoneum, etc but extension or metastasis to the CNS is extremely rare. That is what makes this case a rare one and worthy of sharing.

Keywords: Amoebic liver abscess, brain abscess, fever, pain

How to cite this article:
Shah M, Vij AS, Shah F, Shah F, Seth S, Pandith NA. Amoebic liver abscess with metastatic amoebic brain abscess: A case report. Ann Trop Med Public Health 2016;9:76-9
How to cite this URL:
Shah M, Vij AS, Shah F, Shah F, Seth S, Pandith NA. Amoebic liver abscess with metastatic amoebic brain abscess: A case report. Ann Trop Med Public Health [serial online] 2016 [cited 2020 Sep 18];9:76-9. Available from: https://www.atmph.org/text.asp?2016/9/1/76/174724
Introduction

Amoebic liver abscess is the most common extraintestinal infection by Entameoba histolytica. The regions with the highest incidence (due to inadequate sanitation and overcrowding) of this infection include most developing countries in the tropics, including our country India. [1]

Most patients are febrile and have right upper quadrant pain, which may be dull or pleuritic in nature and may radiate to the shoulder. Jaundice is rare. Older patients are likely to have a subacute course lasting 6 months, [2] with weight loss and hepatomegaly. Liver abscess may be difficult to establish because the signs and symptoms are often nonspecific. [3]

Amoebic abscess of the liver is commonly known to burst into the peritoneal cavity and other abdominal viscera, or into the pleura and the lungs. [4] The involvement of distant organs is rare. Metastatic brain abscess is even rarer (0.1%). [5]

Discussion

We are reporting a case of amoebic liver abscess, with possibility of metastatic amoebic brain abscess.

This young man Mr. Sachin, S/O Mr. Chander Mohan, aged 28 years had a history of 4 months of ill-health. He developed loss of appetite and yellowish discoloration of sclera. There was no history of high color urine or clay color stools, fever, chills, or rigors. He went to Himachal Pradesh to his sister’s house for local treatment of his illness and wanted to have a change of air in order to gain strength. No liver function test (LFT) or other investigations was done and he was put on some medication and diet control and a suspicion of hepatitis was made by a local doctor. He did not get any relief for 2 weeks, and then developed high-grade fever and sever right hypochondriac pain. His fever remained for 4 days but the pain persisted. He was taken to a medical college and hospital in Chandigarh where he was examined and was found to have hepatomegaly with tenderness, and no jaundice. He was advised ultrasound of the abdomen and was given a date a week later for the said investigation. But on the 3rd day, he developed unconscious spell/seizure and fell down. No tongue bite or incontinence was noticed. He was taken to the hospital immediately where he regained his consciousness within 1 h. He did not remember the episode and the accompanying person was not able to give the details. In the hospital, computed tomography (CT) of the head was done that showed a lesion in the left frontal lobe. No impression was made and CT was not reported. The patient was advised to get an ultrasound of the abdomen done on the date already provided. Keeping his condition and severe pain in view, he was taken to a private diagnostic center, which reported space occupying lesion (hepatocellular carcinoma) [Figure 1] and advised CT scan. The patient was admitted on January 20, 2015 to Punjab Institute of Medical Sciences (PIMS) with fever and pain in the right hypochondriac region. He had no history of contact with dogs, dysentery, and surgery in recent past and had no high risk behavior.

Figure 1: Ultrasonography (USG) report

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On examination, he was pale (severely anemic) and emaciated. There was no jaundice. The right hypochondrium was tender; the pain was severe in nature and was radiating to the back.

The liver was 7 cm below the costal margin and was severely tender.

There was no bruit on auscultation.

The chest and cardiovascular system (CVS) examinations were normal and the neurological examination was completely normal.

A possibility of liver abscess was kept in differential diagnosis. Routine investigations showed hemoglobin [Figure 2], blood glucose 149 mg/dL, erythrocyte sedimentation rate [Figure 3], bilirubin 0.9 mg% (total), total proteins 6.6 g/dL, albumin 2.4 g/dL and aspartate aminotransferase (AST) 18 u/L, and alanine aminotransferase (ALT) 20 u/L [Figure 4].

Figure 2: Complete blood count (CBC)

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Figure 3: High ESR

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Figure 4: Biochemistry

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Alkaline phosphatase (ALP) was 785 u/L, gamma-glutamyltransferase (GGT) 376 u/L, urea 13 mg/dL, creatinne 0.9 mg%, uric acid 2.0 mg%, calcium 7.2 mg%, and phosphorous 2.3 mg%.

From routine investigations it was inferred that the patient had very low Hb, high ALP, low albumin, normal platelet count, and very high ESR, and though one reading of TLC was above 13,000, it was normal on other occasions [Figure 5] and [Figure 6].

Figure 5: HIV serology

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Figure 6: Hepatitis serology

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We thought of liver abscess, given the patient’s hepatomegaly, tenderness, previous fever, [Figure 7] and right dome of the diaphragm that was hugely elevated but due to ultrasound and the CT report (CT scan done outside suggested hydatid cyst of liver), the clinical sense got blocked and the patient was admitted with the suspicion of hydatid cyst. The patient was evaluated. [Figure 8] was negative. [Figure 9] was positive.

Figure 7: (a) X-ray of the chest showing raised diaphragm on the right side (b) X-ray showing elevation of the right diaphragm and ground glass appearance of the abdomen

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Figure 8: Hydatid serology

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Figure 9: Amoebic serology

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We sent the patient [Figure 10] and [Figure 11] of the brain and again the report suggested the possibility of hydatid cyst of the brain as [Figure 12] and [Figure 13] was taken into consideration. One more ultrasound that was done in PIMS gave us a report of abscess but it was late. We approached our surgical colleagues and the patient was taken in for surgery with suspected hydatid cyst of the liver after he received 6 units of blood. But on operating the patient, a huge abscess of anchovy sauce nature was found. The abscess was drained and the intercostal tube was kept in for a few days as it drained about 2 liters of pus and the patient was put on treatment. He was discharged on February 20, 2015 with Hb of 10.2 and ESR of 23 mm. He is doing well at present. Patient was seen last on 10/05/2015 and his brain MRI shows that the lesion has cleared and MRI looks perfectly normal.

Figure 10: (a) MRI showing SOL in the frontal lobe (b) Huge abscess in the frontal lobe (c) Frontal lobe showing SOL (d) Frontal lobe abscess in different cuts (e) Frontal lobe abscess (f) Frontal lobe abscess

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Figure 11: MRI of the brain

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Figure 12: (a) CT of the abdomen showing huge liver abscess (b) Liver abscess involving the whole right lobe (c) Huge liver abscess

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Figure 13: Contrast-enhanced computed tomography (CECT) of the abdomen

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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.

References
1.
Khan MH, Qamar R, Shaikh Z. Serodiagnosis of amoebic liver abscess by IHA method. J Pak Med Assoc 1989;39:262-4.
2.
Gridley MF. A stain for Entamoeba histolytica in tissue sections. Am J Clin Pathol 1954;24:243-4.
3.
Craig CF. “Etiology, Diagnosis and Treatment of Amoebiasis.” Williams & Wilkins Co. Baltimore, 1944 as Quoted by Koshy.
4.
Gates EM, Kernohan JW, Craig WM. Metastatic brain abscess. Medicine (Baltimore) 1950;29:71-98.
5.
Armitage FL. Amoebic abscess of brain with notes of a case, following amoebic abscess of liver. J Trop Med Hyg 1919;22:69.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.174724

Figures

[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]

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