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:
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:
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
- Additional clinical questions
- Amoebiasis in Australia
- Travel related infections, case series from SCGH
Abdominal pain in an overseas resident | Micrognome http://bit.ly/9M37uo Mmmm, anchovies