Abdominal pain in an overseas resident

Clinical case of upper abdominal pain in overseas resident

A 54 year old businessman presents with right upper quadrant pain after spending the last six months living in Java.

An ultrasound scan revealed gallstones. A laparoscopic cholecystectomy was then performed. At this point a lesion was observed on the surface of the liver, but not biopsied.

Four months later, on another return visit to Australia, the patient re-presented with fever, a cough and pain radiating to his shoulder tip. He was admitted to a district hospital and a chest X-ray performed. Changes consistent with right lower lobe consolidation were observed and intravenous antibiotics (i.v. Ticarcillin/Clavulanic acid) commenced. The patient did not improve and was transferred to a larger hospital.

After 7 days of intravenous antibiotics he coughed up a large quantity of viscous, brown phlegm with a paste-like consistency. These CT scan views were obtained at this point:

CT thorax after coughing up 'anchovy paste'


CT upper abdomen showing hepatic lesion


The patient’s serum was sent to the Microbiology laboratory with the following result:

Entamoeba histolytica titre > 1:4096

This was seen under the microscope in the paste-like sample of phlegm:

Microscope view of patient's sputum, showing microbe with internalised red cells


Q1   What do the CT scans show?

  • CT thorax: peri-mediastinal opacity
  • CT upper abdomen: smooth-walled lesion within liver

Q2   What object was seen under the microscope?

  • amoebic trophozoite  (Entamoeba histolytica) containing erythrocytes

Q3   What pathological process explains these observations?

  • amoebic liver abscess with trans-diaphragmatic extension and rupture into a bronchiole or bronchus, probably during coughing

Q4   What treatment would you recommend?

  • 750 mg Metronidazole i.v. x3 doses x 10 days
  • followed by paromomycin x3 doses


  1. Abdominal pain in an overseas resident | Micrognome http://bit.ly/9M37uo Mmmm, anchovies

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