Giant liver abscess with bilateral pleural effusion: An unfamiliar association
A 42-year-old male, an occasional alcoholic, presented with dry cough, fever, pain in the lower back, severe vomiting and swelling of both feet since 5-6 days. His clinical signs of vital functions were stable and general physical examination was unremarkable except tachypnea and pitting pedal edema. Chest examination revealed woody dullness, decreased breath sounds, crepitations, and a pleural rub at right infrascapular region. Liver was two fingers enlarged and tender below the costal margin. Cardiovascular examination was essentially normal. A provisional diagnosis of right-sided pleural effusion along with consolidation was kept and a probability of liver abscess was kept. His investigations revealed the following: Hemoglobin (Hb), 12.6 g/dL (15.5 ± 2.5); total leukocyte count (TLC), 24,000/mm3 (400011,000); Erythrocyte Sedimentation Rate (ESR), 70 mm/fall 1st hour (0–10 by Westergreen's method); S. bilirubin total, 0.9 mg/dL (0.2-1.0); serum glutamic oxaloacetic transaminase (SGOT), 104 U/L (8-40); serum glutamic pyruvic transaminase (SGPT), 127 U/L (10-50); alkaline liver phosphatase (ALP), 600 U/L (78-220); S. protein, 6.8 g/dL (6-8); albumin, 3 g/dL (3.4-5); HIV, negative, and HBs Ag, negative. X-ray chest showed raised right half of the diaphragm and mild right-sided effusion. USG abdomen showed liver abscess with around 400 ml of fluid in it. The patient was started on antiamoebic drug metronidazole and antibiotic ceftriaxone on day 1, but pain, breathlessness, and swelling in his feet were not relieved even after 48 h. In view of the persistent symptoms, the abscess was aspirated and about 300 ml of chocolate brown colored pus (anchovy sauce type) was drained out. Microscopic examination of the pus revealed trophozoites of E. histolytica. Despite aspiration and intensive antiamoebic therapy, patient remained breathless and toxic. This prompted us to ask for CT scan of chest and abdomen to find out the extent of abscess and ascertain the presence of any hepatopulmonary complication. CT showed presence of giant liver abscess of the size of about 98 × 108 mm, occupying the segments VI and VII of the liver []. Repeat X-ray showed large amount of fluid now occupying both the pleural cavities. A repeat aspiration was done and around 200 ml pus was tapped. The pleural fluid was also tapped from the right side which was exudate in nature. Serum IgG serology for E. histolytica was strongly positive. Polymerase chain reaction (PCR) was negative for Mycobacterium tuberculosis. Following repeat aspiration of pus and intensive antiamoebic therapy, patient started improving. Pain in abdomen decreased and swelling in the feet disappeared. The initial gastritis remained unexplained but resolved in 2 weeks. Patient became afebrile and regained his appetite. Patient was discharged on maintenance antiamoebic therapy.