Amebic liver abscess

Epidemiology, risk factors, and clinical characteristics of amoebic liver abscess: a systematic review and meta-analysis from India

Amoebiasis and its extraintestinal manifestation amoebic liver abscess (ALA) is an endemic disease in tropical and subtropical countries. However, no meta-analysis on the prevalence, associated risk factors, and clinical markers has been performed. This study aims to bridge this research gap. Based on our inclusion criteria, 18 studies were selected for analysis. Using the "meta" package in RStudio, forest plots, regression analysis, and funnel plots were used to represent the proportional meta-analysis, significance of the correlation, and quality and publication bias of the included studies, respectively. A high prevalence of ALA (67%, p = 1.762 × 10-15) was noted in cases of liver abscess. ALA was significantly more prevalent in males (86%, p = 2.25 × 10-8), individuals with poor socioeconomic conditions (75%, p = 0.02496), history of alcohol consumption (63%, p = 1.421 × 10-8), and diabetic comorbidity (35%, p = 0.01169). There was a significant correlation with abdominal pain (91%, p = 1.286 × 10-12), infected right lobe (81%, p = 0.002), fever (73%, p = 2.567 × 10-12), hepatomegaly (69%, p = 1.223 × 10-5), anemia (69%, p = 1.223 × 10-5), and jaundice (11%, p = 0005258) in the affected individuals. We conclude that the above-stated risk factors and clinical markers are significantly associated with ALA and suggest that medical professionals in endemic regions must attribute liver abscess to be etiologically amoebic and correlate the disease manifestation with the risk factors and clinical markers. Further, research is needed to better understand disease manifestation.

Amebic liver abscess: Clinico-radiological findings and interventional management

In its classic form, amebic liver abscess (ALA) is a mild disease, which responds dramatically to antibiotics and rarely requires drainage. However, the two other forms of the disease, i.e., acute aggressive and chronic indolent usually require drainage. These forms of ALA are frequently reported in endemic areas. The acute aggressive disease is particularly associated with serious complications, such as ruptures, secondary infections, and biliary communications. Laboratory parameters are deranged, with signs of organ failure often present. This form of disease is also associated with a high mortality rate, and early drainage is often required to control the disease severity. In the chronic form, the disease is characterized by low-grade symptoms, mainly pain in the right upper quadrant. Ultrasound and computed tomography (CT) play an important role not only in the diagnosis but also in the assessment of disease severity and identification of the associated complications. Recently, it has been shown that CT imaging morphology can be classified into three patterns, which seem to correlate with the clinical subtypes. Each pattern depicts its own set of distinctive imaging features. In this review, we briefly outline the clinical and imaging features of the three distinct forms of ALA, and discuss the role of percutaneous drainage in the management of ALA.

Pulmonary Thromboembolism: A Rare Vascular Complication of Amebic Liver Abscess

Amebic liver abscess (ALA) is the most common extra-intestinal manifestation of amebiasis. Its complications include rupture into peritoneum, pleural space or anterior abdominal wall. Large abscesses can cause compression of neighboring vascular structures with thrombus formation. Herein, we are presenting an unusual case of a 26-year-old male patient who presented with fever, abdominal pain, chest pain and dyspnea. Ultrasound of the abdomen revealed a lesion in the right lobe of liver and chest radiograph revealed minimal right-sided pleural effusion. A computed tomographic (CT) scan was done in view of unexplained symptoms and a diagnosis of ALA compressing the inferior vena cava (IVC) with subsequent thrombus formation and pulmonary thromboembolism (PTE) was made. He was managed successfully with antibiotics, percutaneous aspiration and anticoagulation.

Hepatogastric Inflammatory Pseudotumor Presumably Deriving from Prior Amebic Infection

Introduction

Inflammatory pseudotumor is a rare entity with a clinical and radiographic presentation that is difficult to differentiate from malignancy. This is a case report of a large hepatogastric inflammatory pseudotumor that presumably developed from a prior amebic pseudocyst.

Case Report

A 14-year-old boy presented with increasing vomiting, epigastric pain, dysphagia, asthenia and weight loss. The clinical history included an amebic infection at the age of 2 months. Instrumental investigations revealed an 8 x 6 cm left subdiaphragmatic mass inseparable from the gastric fundus, which appeared to infiltrate the left hepatic lobe. Surgery disclosed a bulky mass adhering to the gastric fundus and left hepatic lobe that prompted total gastrectomy, resection of the second and third hepatic segments, and Roux-en-Y esophagojejunal loop anastomosis. Histology subsequently confirmed that this was a pseudocyst with a large calcified nucleus surrounded by myofibroblastic proliferation associated with a diffuse lymphoplasmacytic infiltrate affecting the gastric wall and hepatic parenchyma, hence the final diagnosis of inflammatory pseudotumor, presumably in response to a prior amebic pseudocyst.

Conclusions

Inflammatory pseudotumor is a rare entity that is seldom found in the stomach. The particular interest of the present case lies in the fact that it developed in the stomach and liver, presumably deriving from a previous amebic pseudocyst.

Management of Liver Abscess in Children: Our Experience

Introduction

Liver abscess is common in pediatric population in India. Children have unique set of predisposing factors and clinical features. Liver abscesses are infectious, space-occupying lesions in the liver; the two most common abscesses being pyogenic and amebic. Its severity depends on the source of the infection and the underlying condition of the patient.

Materials and methods

A total of 34 patients less than 12 years were assessed in a retrospective study from January 2012 to 2016. Patients were assessed in terms of age of presentation, etiology, bacteriology, diagnosis, and modality of treatment.

Results

The mean age of presentation was 6.3 years. Average volume of abscess was 164 cc. Nine patients (26.4%) underwent percutaneous needle aspiration under ultrasound guidance with wide bore needle (18 G disposable needle). Three patients required more than two sittings of aspiration. Patients with volume more than 80 cc were treated with catheter drainage. Twenty patients (58.8%) underwent ultrasound-guided percutaneous catheter drainage. Two patients required catheter drainage for large abscess and needle aspiration for the smaller abscess.

Conclusion

Antimicrobial therapy along with percutaneous drainage constitutes the mainstay of treatment, whereas open surgical drainage should be reserved for selected cases.How to cite this article: Waghmare M, Shah H, Tiwari C, Khedkar K, Gandhi S. Management of Liver Abscess in Children: Our Experience. Euroasian J Hepato-Gastroenterol 2017;7(1):23-26.

Unusual complication of amebic liver abscess: Hepatogastric fistula

Amebic liver abscess is a parasitic disease which is often encountered in tropical countries. A hepatogastric fistula secondary to an amebic liver abscess is a rare complication of this disease and there are only a handful of reported cases in literature. Here we present a case of an amebic liver abscess which was complicated with the development of a hepatogastric fistula. The patient presented with the Jaundice, pain and distension of abdomen. The Jaundice and pain improved partially after he had an episode of brownish black colored increase in frequency of stools for 5 to 6 d. Patient also had ascites and anemia. He was a chronic alcohol drinker. Esophagogastroduodenoscopy performed in view of the above findings. It showed a fistulous opening with bilious secretions along the lesser curvature of the stomach. On imaging multiple liver abscesses seen including one in sub capsular location. The patient was managed conservatively with antiamebic medications along with proton pump inhibitors. The pigtail drainage of the sub capsular abscess was done. The patient improved significantly. The repeat endoscopy performed after about two months showed reduction in fistula size. A review of the literature shows that hepatogastric fistulas can be managed conservatively with medications and drainage, endoscopically with biliary stenting or with surgical excision.

Endoscopic ultrasound-guided drainage of an amoebic liver abscess extending into the hepatic subcapsular space

Here, we report a case of an amoebic liver abscess (ALA) successfully treated with endoscopic ultrasound (EUS)-guided liver abscess drainage (EUS-LAD). A 37-year-old male with a liver abscess was referred to our hospital due to disease progression despite receiving antibiotic therapy. Computed tomography showed an intrahepatic abscess extending into the hepatic subcapsular space. The abscess could not be punctured through the hepatic parenchyma percutaneously due to the presence of hepatic subcapsular lesions. Hence, EUS-LAD was performed via the transhepatic approach through the stomach. A 5-Fr pigtail-type nasocystic tube was inserted into the abscess through the hepatic parenchyma, with no procedure-related complications. The contents of the abscess had the appearance of anchovy paste which made us suspect an amoebic abscess; therefore, we started antibiotic therapy with metronidazole. Afterwards, serum anti-amoebic antibodies were found to be positive and the diagnosis of ALA was confirmed. Two weeks later, the size of the abscess decreased, and the patient's clinical symptoms disappeared. Hence, the tube was removed. There were no signs of recurrence during the follow-up period. The use of EUS-LAD for pyogenic or tuberculous abscesses has been reported previously. EUS-LAD for an ALA, similar to that for other liver abscesses, is an effective alternative to percutaneous transhepatic abscess drainage or surgical treatment.

Cystic hepatic lesions: a review and an algorithmic approach

OBJECTIVE

The purpose of this article is to review the different cystic hepatic lesions, with an emphasis on the imaging features that help to differentiate them, and to propose a practical algorithm for approaching the diagnosis of these lesions.

CONCLUSION

The number and morphology of the lesions and determination of whether there is a solid component are key imaging features that are helpful for approaching the diagnosis of cystic hepatic lesions. Familiarity with these features and knowledge of the clinical associations will help the radiologist to establish a definitive diagnosis or provide a reasonable differential diagnosis.

Unusual presentation of tuberculosis in an elderly male: a case report

Tuberculous liver abscess is an extremely rare condition, even in tuberculosis endemic countries. A 68-year-old male presented with 2 months of fever, significant weight loss, and hepatomegaly. Ultrasonography revealed a right hepatic lobe abscess. Guided aspiration of the fluid showed tubercular bacilli. He had no evidence of active Tuberculosis elsewhere.

Production of recombinant Entamoeba histolytica pyruvate phosphate dikinase and its application in a lateral flow dipstick test for amoebic liver abscess

BACKGROUND

Amoebic liver abscess (ALA) is the most common clinical manifestation of extraintestinal amoebiasis especially in developing countries, causing up to 100 000 fatal cases annually. Accurate and early diagnosis is important to prevent the disease complications, however its diagnosis still poses many challenges due to the limitations of the available detection tools. Pyruvate phosphate dikinase (PPDK), an excretory-secretory protein of E. histolytica, has been reported as a potential diagnostic marker for ALA, hence it may be exploited in the development of a new test for ALA.

METHODS

Recombinant PPDK (rPPDK) was expressed, purified and evaluated by Western blot. In parallel, recombinant galactose-and-N-acetyl-D-galactosamine inhibitable lectin (Gal/GalNAc lectin) was produced and tested similarly. The protein identity was confirmed by analysis using MALDI-TOF/TOF. A lateral flow dipstick (LFD) test using rPPDK was subsequently developed (rPPDK-LFD) and evaluated for serodiagnosis of ALA.

RESULTS

rPPDK was expressed as soluble protein after 4 hours of induction with 1 mM isopropyl β-D-1-thiogalactopyranoside (IPTG) at 30°C. Purification using nickel-nitrilotriacetic acid (Ni-NTA) resin yielded 1.5 mg of rPPDK from 1 L of culture with estimated molecular mass of 98 kDa on SDS-PAGE. Western blots using sera from patients with ALA, healthy individuals and other diseases probed with anti-human IgG4-HRP showed the highest sensitivity (93.3%) and specificity (100%); as compared to blots using IgG and IgG1 as secondary antibodies. Moreover, rPPDK showed better specificity when compared to rGal/GalNAc lectin. In the development of the LFD test, the optimum amount of rPPDK was 0.625 μg per dipstick and the optimum working concentration of colloidal gold conjugated anti-human IgG4 was optical density (OD) 5 (1.7 μg of anti-human IgG4). Evaluation of rPPDK-LFD using ALA patients and controls serum samples showed 87% diagnostic sensitivity and 100% specificity.

CONCLUSION

The developed rPPDK-LFD showed good potential for rapid diagnosis of ALA, and merit further multicentre validation using larger number of serum samples.

Unusual multiple large abscesses of the liver: interest of the radiological features and the real-time PCR to distinguish between bacterial and amebic etiologies

We report a rare case of amebiasis generating 19 large liver abscesses. Such a quantity of abscesses is rare, especially when occurring in a young casual traveler without any immunodeficiency disorders. A possible co-infection was excluded. By contrast, the amebic etiology was confirmed by means of serology and real-time PCR.

Synthesis, characterization, and anti-amoebic activity of N-(pyrimidin-2-yl)benzenesulfonamide derivatives

A new series of N-(pyrimidin-2-yl)benzenesulfonamide derivatives, 3a-3i and 4a-4i, was synthesized from pyrimidin-2-amines, 2a-2i, with the aim to explore their effects on in vitro growth of Entamoeba histolytica. The chemical structures of the compounds were elucidated by elemental analysis, FT-IR, (1) H- and (13) C-NMR, and ESI mass-spectral data. In vitro anti-amoebic activity was evaluated against HM1 : IMSS strain of Entamoeba histolytica. The IC50 values were calculated by using the double dilution method. The results were compared with the IC50 value of the standard drug 'metronidazole'. The selected compounds were tested for their cytotoxic activities by cell-viability assay using H9C2 cardiac myoblasts cell line, and the results indicated that all the compounds displayed remarkable >80% viabilities to a concentration of 100 μg/ml.

Clinical manifestations and risk factors of amebic liver abscess in Southeast Taiwan compared with other regions of Taiwan

Amebic liver abscess (ALA) had previously been endemic in Taiwan, particularly in the southern region, although its occurrence in the southeastern area was unknown. Thus, we conducted a retrospective study for southeastern Taiwan. We identified 14 patients who were diagnosed with ALA between July of 1995 and July of 2008. These patients were predominantly male and older in age. Most patients lived in rural areas (85.7%). Alcoholism (78.6%) and diabetes (35.7%) were risk factors for ALA. No human immunodeficiency virus (HIV) infections were detected. The most common clinical symptoms were fever (100%) and abdominal pain (100%). Short mean durations of symptoms, high bilirubin levels, and low albumin levels were also noted. Most patients (92.86%) had a single lesion, particularly in the right liver lobe (71.4%). Six patients also had secondary Klebsiella pneumoniae bacterial infections. Clinicians should be aware of the different risk factors in different regions when diagnosing amebic liver abscess in Taiwan.

Inferior vena cava thrombosis in a pediatric patient of amebic liver abscess

Amebic liver abscess (ALA) in pediatric age group is rare. We describe a successful thrombectomy and open drainage of a large left lobe ALA associated with thrombus in the hepatic veins and inferior vena cava extending into the right atrium in a 6-year-old boy.

Evaluation of Entamoeba histolytica recombinant phosphoglucomutase protein for serodiagnosis of amoebic liver abscess

Background

Amoebic liver abscess (ALA) is the most frequent clinical presentation of extra-intestinal amoebiasis. The diagnosis of ALA is typically based on the developing clinical symptoms, characteristic changes on radiological imaging and serology. Numerous serological tests have been introduced for the diagnosis of ALA, either detecting circulating amoebic antigens or antibodies. However those tests show some pitfalls in their efficacy and/or the preparation of the tests are costly and tedious. The commercial IHA kit that used crude antigen was reported to be useful in diagnosis of ALA, however high antibody background in endemic areas may cause problems in its interpretation. Thus, discovery of well-defined antigen(s) is urgently needed to improve the weaknesses of current serodiagnostic tests.

Methods

Crude antigen of E. histolytica was analysed by 2-DE and Western blot to identify a protein of diagnostic potential for ALA. The corresponding gene of the antigenic protein was then cloned, expressed and the purified recombinant protein was subsequently evaluated for serodiagnosis of ALA in an indirect ELISA format.

Results

Analysis of crude antigen showed that phosphoglucomutase (PGM) has the diagnostic potential. Recombinant PGM (rPGM) showed 79.17% (19/24) sensitivity and 86.67% (195/225) specificity in diagnosis of ALA based on the COV of mean +1SD. There was no significant difference between rPGM-ELISA and IHA diagnostic kit in the diagnosis of ALA in terms of sensitivity and specificity at p-value < 0.05.

Conclusion

In conclusion, rPGM-ELISA is found to be useful for serodiagnosis of ALA. Future studies will determine whether rPGM-ELISA also detects antibodies produced in amoebic dysentery and asymptomatic cases.

Parasitic liver disease in travelers

Liver disease is an important source of morbidity among ill returning travelers. Jaundice is one of the most common and obvious symptoms of liver disease, the differential diagnosis of which is extensive, especially in travelers. Jaundice in travelers can arise from both infectious and noninfectious causes. We herein summarize the most common parasitic etiologies that may lead to jaundice in the returned traveler, visitors of friends and relatives, or new immigrants, and describe the etiology, epidemiology, and pathogenesis of clinical features of each.

Hepatic abscesses

Hepatic abscesses are potentially lethal diseases if early diagnosis and treatment are not instituted. They are prevalent all over the globe and pyogenic abscesses are predominant over amoebic. With better control of intra abdominal and systemic infections by a spectrum of antibiotics, aetiology of pyogenic abscesses are secondary to interventions and diseases in the biliary tree to a large extent today. The common organisms isolated are the Gram negative group. Amoebic abscesses continue to plague some regions of the world where hygiene and sanitation are questionable. Over the years, diagnosis, treatment and prognosis have evolved remarkably. Imaging modalities like ultrasonography and CT scan have become the cornerstone of diagnosis. The absence of ionizing radiation makes MRI an attractive alternative in patients who require multiple follow up scans. Serological testing in amoebic abscesses has become more reliable. Though antibiotics have remained the principal modality of management, percutaneous drainage of abscesses have vastly improved the chances of cure and bring down the morbidity drastically in pyogenic abscesses. Amoebic abscesses respond well to medical treatment with nitroimidazoles, and minimally invasive surgical drainage is an option in cases where open surgery is indicated.

Effect of bovine lactoferrin in a therapeutic hamster model of hepatic amoebiasis

Entamoeba histolytica is the causative agent of amoebiasis, a disease that produces dysentery as a result of the perforation of the large intestine. This parasite often invades other organs, primarily the liver, leading to an amoebic liver abscess (ALA), which can cause death. Metronidazole is the drug of choice for the treatment of ALA; however, it produces toxic side effects in patients. Lactoferrin (Lf) is a glycoprotein of the innate immune response that sequesters iron in the mucosae. Lf possesses immune-regulatory properties, such as antiinflammatory and antioxidant activities. Moreover, the microbicidal activity of apoLf, which lacks bound iron, has been shown. In this study, we evaluated the therapeutic effect of bovine Lf (bLf) against ALA in a model of hepatic amoebiasis in hamsters. Interestingly, hamsters treated intragastrically with Lf (2.5 mg/100 g mass) over a period of 8 days showed no clinical signs of disease and ALA was effectively decreased, with only 0.63% detectable lesion, compared with 63% in untreated animals. Furthermore, liver function and blood cells approached normal levels among those receiving bLf treatment. These results suggest that bLf may aid in the therapy of amoebiasis, likely without producing undesirable effects in patients.

Three cases of amoebic liver abscess causing inferior vena cava obstruction, with a review of the literature

Amoebic liver abscess is a common disease, especially in endemic areas, but it is a rare cause of inferior vena cava (IVC) obstruction, with only a few cases appearing in the literature. We report three cases of amoebic liver abscess complicated with obstruction of the IVC and which responded to conservative treatment or radiological intervention.

Liver abscess in children: an overview

BACKGROUND

Liver abscess (LA) in the pediatric population has become relatively uncommon in developed countries but it continues to have a high incidence among children in developing countries. This article aims to review the trends in all aspects of LA in children, both temporally and geographically.

DATA SOURCES

The PubMed and Google Scholar database were searched with the keywords "liver abscess", "children", "predisposing causes", "clinical signs and symptoms", "treatment" from 1975 to 2009 and all kinds of retrospective and prospective studies, reviews, case series were included.

RESULTS

Pyogenic LA constitutes the majority of cases, followed by amebic and fungal LA. Staphylococcus aureus is the most common pathogen worldwide. Ultrasonography (US) and computed tomography (CT) are widely used as diagnostic tools. There are varying opinions regarding the treatment of LA in children. The general trend is towards less invasive modalities of treatment like percutaneous drainage along with antimicrobial drug therapy. However, in selected patients, open surgical drainage still plays an important role. The mortality rate for pyogenic LA has shown a decline from about 40% before the 1980s to less than 15% in the recent years. At the same time, the mortality rate of amebic LA cases reported to be around 11%-14% before 1984 has reduced to less than 1% at present.

CONCLUSIONS

Etiological pattern of LA in children has remained the same over the years, and in most regions, it is associated with Staphylococcus aureus and amebic LA is quite uncommon. US or CT scan is the most frequently employed diagnostic modality for LA, and follow-up is usually performed by serial US scans. Antimicrobial therapy along with, if necessary, drainage of the abscess by either percutaneous or open surgical route remains the treatment of choice.

Amoebic liver abscess: experience in a south Asian country

Amoebic liver abscess (ALA) is endemic in south Asian countries. The current study was undertaken in order to evaluate the clinical spectrum, management and outcome of ALA at an urban tertiary care hospital in Pakistan. The chart notes of 232 ALA patients admitted from 1 January 2000 to 31 August 2007 were retrospectively reviewed. The most frequent clinical findings included: fever (96.5%); right upper abdomen pain (80.2%); liver tenderness (73.5%); tachycardia (61.6%); hepatomegaly (60%); nausea and vomiting (42%); and jaundice (23.9%). The duration of symptoms was less than 14 days in 70% . Ultrasound examinations revealed 69% of the abscesses were in the right lobe, 19% in the left lobe and 12% in both lobes. The size of the abscess was greater than 5.0 cm in 83%. Seventy-seven percent of the patients had a single abscess and 23% had multiple abscesses. Ultrasound-guided therapeutic aspiration was performed in 64%, but 36% were treated with antibiotics alone. Metronodazole was the most frequently used antibiotic. However, various combinations of antibiotics were also used without any obvious justification.

Pseudoaneurysm of the hepatic artery, a rare complication of an amebic liver abscess

Hepatic artery pseudoaneurysm is a rare complication of amebic or pyogenic liver abscesses, and it is generally diagnosed because of hemobilia due to rupture of the aneurysm into the biliary tract. The authors describe a case of vascular complication in a patient affected by amebic liver abscess. Pseudoaneurysm was diagnosed and resolved without hemobilia.

Simultaneous Klebsiella pneumoniae and amoebic liver abscess in an immunocompetent patient

Simultaneous Klebsiella pneumoniae and amoebic liver abscess is rarely reported in immunocompetent patients. A 47-year-old man was hospitalized with abdominal pain, fever, chills, and hypotension. Physical examination revealed right upper quadrant tenderness. Abdominal computed tomography showed an area of low attenuation with some liquefaction in the liver. Echo-guided aspiration revealed 30 mL of pus, which grew Klebsiella pneumoniae, and the same organism was isolated from the blood. Cytology examination of the pus showed scattered amoeba. The patient gradually improved over 1 month on treatment with cefmetazole and metronidazole, along with repeated drainage of the abscess. His amoebic indirect hemagglutination titer was 1:128, but no parasite ova or amoeba were found in the stool. He had no evidence of immunocompromise. Parasitic diseases may be a predisposing factor for bacterial infections, including pyogenic liver abscess. The possible coexistence of amoebae and bacteria in a liver abscess should not be discounted.

Entamoeba histolytica sequences and their relationship with experimental liver abscesses in hamsters

The purpose of the present paper was to analyse the association between sequences of Entamoeba histolytica and their relationship with the development of hepatic abscesses in hamsters, using a complementary DNA library for E. histolytica. From the sequences obtained, we designed oligonucleotides for amplification by PCR. Trophozoites were isolated from faeces of 11 patients in whom cysts from E. histolytica were identified, and these trophozoites were then subjected to monoaxenic culture. Then 1 x 10(5) trophozoites were inoculated into hamster liver, with three hamsters used for every culture. Sequences were obtained for ubiquitin, lectin surface precursor, replication factor MCM3 and surface antigen. The associations between sequences and hepatic abscesses were: 11/11 for ubiquitin, 9/11 for lectin precursor, 4/11 for replication factor and 1/11 for surface antigen. These results suggest that ubiquitin could be an important protein involved in the mechanism of E. histolytica invasion.