A 52 y.o. baseball fan returned from the Dominican Republic with flu-like symptoms and abdominal pain.
This patient had an amebic liver abscess. A liver abscess is the most common extraintestinal manifestation of Entamoeba histolytica. Amebic infection is common in South America and the Carribean. It is presumed the patient was infected in the Dominican Republic. Most commonly infection occurs 14 days after exposure but symptomatic infection has been reported up to 12 years after exposure.
Pathophysiology
E histolytica exists in two forms: cysts and trophozoites. The cysts are ingested in contaminated water and are resistant to gastric acid; their walls are broken down by trypsin in the small intestine. The trophozoitesthen colonize the large bowel. In 4% of patients with amebic colitis, the trophozoites invade the wall of the bowel and travel through the portal vein forming liver abscesses.They contain a lectin protin which causes tissue invasion and can develop abscesses that rupture into the pleural space, heart or peritoneum. Spread can also be hematogenous causing pneumonia and bronchopulmonary fistulae. Sputum in these cases is described as looking like “anchovy paste”.
Diagnosis
Diagnosis can rarely be made by looking for cysts or trophozoites in stool. The serum ELISA has become the diagnostic method of choice.
Treatment
The treatment is initially flagyl followed by an enteric amebicide.
Conclusion of the case
This patient had a very complicated course. He presented with fever, abdominal pain and flu- like symptoms. His initial liver abscess was discovered at an outside hospitalandgrew out strep anginosus. (It is not uncommon for amebic abscesses to have bacterial superinfection. ) He was treated with multiple antibiotics including flagyl on arrival to Washington University. The patient developed septic shock with a prolonged period on pressors, liver biopsy with retroperitoneal bleed, ischemic bowel with a small bowel perforation and resection, enterocutaneous fistula treated with TPN, multiple bouts of line sepsis on TPN and dvts. One year later, he is back to work and doing well.
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bowel wall abscess from E. histolyticqa