Case Report: Amoebic Liver Abscess In Newly Detected HIV Infection
Amoebic liver abscess is a most common extraintestinal manifestation of amoebiasis which is most commonly present with high grade fever with right upper quadrant abdominal pain. Here we present a case of 32 year male patient newly diagnosed as People Living with HIV/AIDS (PLHIV) withamoebic liver abscess (ALA). Patient was treated with Metronidazole (500 mg 8hrly) and therapeutic drainage.
Introduction
Liver abscesses are divided into pyogenic and amoebic liver abscess. Amoebiasis is an infection caused by intestinal protozoa Entamoeba histolytica (E. histolytica).
E. histolytica was first described by Losch in 1875. About 90% symptoms are asymptomatic and remaining 10% causes variety of clinical syndromes. Amoebic Liver Abscess (ALA) is the most common extraintestinal manifestation of amoebiasis. ALA usually presents as an acute illness with right upper quadrant pain, fever and tender hepatomegaly. Poor hygiene, malnutrition, immunosuppression and oral anal sexual practise increases risk for developing ALA.
Patients with human immunodeficiency virus (HIV) represents one of the highest risk for invasive amoebiasis. HIV infected patients with invasive amoebiasis are predominantly men who have sex with men.
Case Report
A 32 year old male patient was admitted with complains of high grade fever which was intermittent in nature and right upper quadrant abdominal pain since 15 days. Patient also had weight loss of about 5 kilogram in last one month. There were no history of cough, night sweats, loose stools, vomiting and headache. On admission patient was febrile, vitals were stable with tender hepatomegaly. Laboratory parameters at time of admission are shown in table number one. Patient underwent non invasive imaging. USG abdomen showed poorly defined hypoechoic lesion (3. 3×4. 8 cm) with irregular, lobulated hyperechoic margins and CECT abdomen had hypodense oval lesion measuring (4. 5×4×4. 1 cm) in segment IVa of liver with enlarged liver (15. 7 cm).
Patient underwent ultrasound guided percutaneous drainage of solitary liver abscess with all aseptic precautions and informed written consent. Around 60 ml of abscess fluid was removed and examined for cytology, staining and ADA. Subsequently patient’s serum IgG level for amoeba sent which was positive for Entamoeba histolytica (value 5. 85, ref. value < 0. 90).
Patient was diagnosed as Amoebic Liver Abscess in a newly diagnosed PLHIV. Patient was treated with IV antibiotics (Metronidazole 500mg 8hrly and Ceftriaxone 1gm 12hrly for 10 days) and percutaneous ultrasound guided therapeutic abscess drainage (around 60 ml) with informed and written conscent. Patient’s fever and abdominal pain subsided after 48 hrs of starting metronidazole and improved significantly. Patient was discharged on Anti Retroviral Therapy (ART) and Tablet Iodoquinol (650 mg 8hrly for 20 days) and asymptomatic on follow up.
Discussion
Amoebic liver abscess (ALA) develops in 10% of patients who develops amoebiasis. ALA is more commonly seen in young adults. A study done on clinical presentation of ALA on 62 Thai patients showed that in liver amoebiasis infection starts with ingestion of amoebic cysts which after excystation from trophozoites in small intestine colonize the bowel lumen and invade the intestinal epithelium which results in intestinal amoebiasis and spreading to liver causes ALA.
ALA usually presents with fever and right upper quadrant pain but sometimes it can be presented with right shoulder pain. ALA most commonly present over right lobe of liver as a single solitary lesion. ALA is diagnosed with stool examination for E. histolytica, non invasive studies of liver (USG Abdomen or CECT abdomen), serology test for amoeba and abscess fluid examination for amoeba. Kuan Sheng Wu et al had reported diagnostic criteria for ALA which are shown in table three. Our patient had high grade fever with right upper quadrant pain and imaging study shows abscess with serology positive for E. histolytica. Studies showed use of Metronidazole (750 mg 8hrly) with Iodoquinol (650 mg 8hrly) for treating ALA.
Criteria for diagnosis of ALA
- Clinical symptoms like fever, chills and abdominal pain
- Radiological findings of liver abscess on ultrasound or computed tomography
- Negative bacterial culture of liver abscess aspirate
- Response to Metronidazole
- History of travel to endemic area.
Meng Shuian et al noted thatthose causative organisms are same in both HIV infected patient and non HIV patient for developing liver abscesses. It is believed to be dysregulation of T cell activity in patient with HIV for developing ALA. Study also showed that clinical feature are same in both group patients. Viroj Wiwanitkit’s study on 62 patient with HIV infection had shown less frequently fever and abdominal pain occurred with lower WBC count, AST and ALT levels (due to reduced inflammatory response related to HIV) and high IHA titre noted.
Studies done on CD4 count in HIV infected patient having ALA shows range of CD4 count between 14 to 798/ul but in 95% of patients CD4 count is between 200 to 349/ul. In our case CD4 count was 215/ul. A study by Terry Wuerz et al on review of amoebic liver abscess for clinicians in nonendemic setting reported that serologic test by enzyme linked immunosorbent assay has a sensitivity of 94% and specificity of 95%. They also reported gold standard treatment for ALA which consists of Metronidazole (750 mg 8hrly) for 7 to 10 days followed by luminal amebicide.
Terry Wuerz et al had given differential points between ALA and pyogenic liver abscess which was similar to given by Viroj Wiwanikit.
The most common complication of ALA is pleuropulmonary involvements which manifest as sterile effusion and rupture into pleural cavity. Other complications are rupture of abscess into peritoneum and pericardium. Cerebral involvement into ALA occurs in < 0. 1% patients. In our case patient was treated with Metronidazole (750 mg 8hrly) and Ceftriaxone (1 gm 12hrly). Patient improved well with above treatment and did not have any complication. Our patient was discharged on luminal antiamoebic (Iodoquinol 650 mg 8hrly), anti-retroviral therapy (Tenofovir 300mg, Lamivudine 150mg and Efavirenz 600mg) and advised for regular follow up.
Conclusion
As amoebic liver abscess (ALA) is the most common extraintestinal manifestation of amoebiasis which sometimes presents as only fever, hence one should keep in mind as a differential while evaluating fever of unknown origin (FUO). ALA presents as initial manifestation for more than half of HIV infected patient hence one must screen for HIV in ALA. Early diagnosis and treatment in ALA has good prognosis.
Preventive measures for amoebiasis include adequate sanitation and eradication of cyst carriage because an asymptomatic carrier may excrete up to 15 millions cysts per day.
