Description

A 57-year-old lady presented with a 6-day history of fever, abdominal pain, vomiting, constipation and weight loss. Her medical history included treatment with ramipril for hypertension and diverticular disease. She had been on holiday in the Dominican Republic 18 months ago and had visited Gambia a few weeks prior to admission. She had taken full malaria prophylaxis.

On examination she was pyrexial with a temperature of 40° associated with a tachycardia. Abdominal examination revealed right upper quadrant tenderness. Full blood count showed a mildly elevated white cell count of 10.1×10⁹/l (normal 3.6–9.2), C reactive protein was greater than 250 mg/l (normal <7). Amylase, urea and creatinine were all normal. Her liver function was deranged with an alkaline phosphatase of 234 IU/l (normal 30–130), alanine transaminase of 76 IU/l (normal 10–50), bilirubin of 25 μmol/l (normal 2–20), γ glutamyl transferase of 276 IU/l (normal 5–40).

The patient was started empirically on metronidazole 500 mg intravenous three times a day. Initial liver ultrasound showed multiple well defined hypoechoic lesions suspicious of metastases, however further imaging with CT and MRI showed peripheral rim enhancement suggestive of multiple hepatic abscesses (at least six) (figures 1 and 2). Serology for immunofluorescence antibody amoebiasis was strongly positive 1 in 1024 titre. Stool cultures were negative. The patient received a total of 21 days of metronidazole and 10 days of diloxanide furoate 500 mg three times a day to clear her luminal trophozites. The patient responded well with resolution of her abscesses without the need for aspiration or drainage(figure 3).

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Figure 1

CT abdomen showing multiple low attenuation liver lesions with peripheral rim enhancement.

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Figure 2

MRI Liver showing multiple cystic thickwalled, rim enhancing masses. The lesions return high signal on dual echo T2, consistent with multiple hepatic abscesses.

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Figure 3

CT abdomen showing complete resolution of the liver lesions.

It is important to note that aspiration of amoebic abscesses is not required for diagnosis or treatment and is only indicated if rupture is felt to be imminent. Sensitivity of non-invasive tests such as serum and stool enzyme immunoassay or newer PCR techniques tend to offer sensitivity >90% with excellent specificity. Serological and antigen tests normally revert to negative after successful treatment within a week. Equally, regression of the abscesses can also be expected within a week of treatment and can be further confirmation of the diagnosis.