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Persistent fever and right hypochondrium pain
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  1. Thomas Roland1,
  2. Halil Yildiz2,
  3. Bernard Vandercam1,
  4. Lucie Pothen2
  1. 1 Infectiology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
  2. 2 Internal Medicine, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
  1. Correspondence to Dr Halil Yildiz, halil.yildiz{at}uclouvain.be

https://doi.org/10.1136/bcr-2017-221254

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    Description

    A 39-year-old patient was admitted to our hospital for 10 days fever (up to 40°C) with pain in the right hypochondrium. Abdominal echography performed at the onset of symptoms was normal. Blood tests showed C-reactive protein 311 mg/L, leucocytes count 24x109 /L (neutrophils count at 19, 29x109/L), bilirubin 1.1 mg/dL, lactate dehydrogenase (LDH) 254 U/L, aspartate aminotransferase (ASAT) 67 U/L, alanin aminotransferase (ALAT) 66 U/L, gammaGlutamyltransferase (gGT) 79 U/L and alkaline phosphatase 221 U/L. Chest X-ray showed an infiltrate in the right lung base. A diagnosis of pneumonia was made and treatment with cefuroxime started. Since fever and right hypochondrium pain persisted despite antibiotherapy for 5 days, abdominal CT scan was performed, which demonstrated a large hepatic mass of 10×7 cm (figure 1). Percutaneous drainage revealed a thick and brown liquid; ‘chocolate-like’ (figure 2). Complementary information came from anamnesis: the patient usually lives in Cambodia and he has had dysentery 3 months ago. Clinical and biological evolution was well under metronidazole 500 mg three times a day for 10 days. Entamoeba serology (antibody detection with indirect fluorescent antibody technique) came back positive (1/800). A diagnosis of amoebic abscess was retained and the patient completely recovered at the end of the treatment (paromomycin for 7 days after metronidazole). Amoebic liver abscess is caused by Entamoeba histolytica.1 Antibiotic such as metronidazole is the usual treatment for liver abscess. Paromomycin has also to be taken to prevent the recurrence. In rare cases, the abscess may need to be drained to relieve some of the abdominal pain (abscesses greater than 5 cm).2

    Figure 1
    Figure 1

    Abdominal CT scan showing a large hepatic mass.

    Figure 2
    Figure 2

    ‘Chocolate-like’ liquid coming from the percutaneous drainage of the liver abscess.

    Learning points

    • Hepatic abscess in a patient returning from a tropical zone evokes Entamoeba histolytica abscess.

    • Importance of aspiration for abscesses greater than 5 cm. In amoebic abscess, liquid has usually a brown appearance, chocolate-like.

    • Treatment consists in metronidazole for trophozoites (500 mg three times a day for 10 days) and paromomycin for cystic forms (500 mg four times a day) during 7 days.

    References

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      2. Stanley SL
      . Amoebiasis. The Lancet 2003;361:1025–34.doi:10.1016/S0140-6736(03)12830-9
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      2. Lübbert C ,
      3. Wiegand J ,
      4. Karlas T
      . Therapy of liver abscesses. Viszeralmedizin 2014;30:334–41.doi:10.1159/000366579
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    View Abstract

    Footnotes

    • Contributors Dr TR and Dr LP contributed equally to the writing and the management of the patient. Dr HY and Professor BV helped in the writing and the management of the patient.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.