Amoebic liver abscess

Case contributed by Ashesh Ishwarlal Ranchod
Diagnosis almost certain

Presentation

Right hemiabdominal pain, pyrexia, and rigors. Recent travel history.

Patient Data

Age: 60 years
Gender: Male
ultrasound

There is a large, irregular, mixed echogenic intrahepatic mass lesion within the right lobe of the liver. Evidence of internal echoes and septations. There is no biliary dilatation. Features suggestive of a hepatic abscess.

ct

There is a large, irregular, cystic, septated, intrahepatic mass lesion within the right lobe of the liver. There is faint wall enhancement with perilesional edema ("double target sign"). The lesion measures approximately 30-40 HU. There is a smaller lesion within segment IVb. Features consistent with a large hepatic abscess. There is no biliary obstruction. The gallbladder, pancreas, pancreatic duct, and spleen are normal.

There is large bowel diverticulosis and focal sigmoid diverticulitis. There is no intrapelvic abscess or collection.

The renal tracts are normal.
There is known L3 to S1 posterior spinal fusion and decompression laminectomy with accelerated degeneration superior to the fusion.

Anchovy paste aspirate

Photo

A diagnostic aspiration was performed prior to a broad-spectrum antibiotic, and antiprotozoal therapy. The aspirate revealed anchovy paste pus suggestive of an amoebic hepatic abscess.

Case Discussion

Features suggest an amoebic hepatic abscess based on imaging features and the aspiration of pink pus resembling anchovy paste. The patient had a positive recent travel history and experienced symptoms on returning home. There is focal sigmoid diverticulitis (Hinchey classification- stage 1a). In cases of complicated acute diverticulitis, hepatic abscesses are usually bacterial rather than amoebic. In this instance, it is uncertain if the focal acute sigmoid diverticulitis is the source of the amoebic abscess or an incidental finding. Clinically the patient had no symptoms suggestive of amoebic colitis/ dysentery. Stool and blood sampling were recommended for further investigation. After a few days of antibiotics and antiprotozoal medications, an ultrasound-guided pigtail aspiration was performed and 1.5 liters of anchovy paste pus was drained.

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