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• W2008304859 abstract "A 23-year-old male was admitted in emergency with high-grade fever and pain in the right lower chest for the last 1 week. He developed productive cough with copious amount of reddish brown sputum, for the last 2 days. On examination, he was found to be febrile with a temperature of 101°F, a pulse rate of 110/min, respiratory rate of 30/min, and blood pressure (BP) within normal range. His blood investigations were within normal limits. On examination, there was intercostal tenderness in the right lower chest and abdominal examination was normal. Chest auscultation revealed decreased breath sounds in the right base with bronchial breathing and coarse crepts. Chest X-ray revealed non-homogeneous opacity in the right lower zone with obliteration of the costophrenic angle [Figure 1]. The patient was previously being treated on lines of pneumonitis with broad-spectrum antibiotics and expectorants but there was no response. On admission, ultrasound of the abdomen revealed a 5.7 × 6.0 cm hypo-echoic lesion in segment VII of the liver. Thereafter, contrast-enhanced computerized tomographic (CT) scan of the abdomen and chest was performed [Figure 2] and a definitive diagnosis was made. The patient was given specific treatment and he improved dramatically.Figure 1: Chest X.ray showing non.homogeneous opacity in the right lower zone, with obliteration of the right costophrenic angleFigure 2: Contrast.enhanced CT scan of the abdomen showing a 5.0 × 6.0 cm liver abscess with air in it seen in segment VII of the liver, reaching the sub.diphragmatic space and communicating with the right pleural cavity. There is collapse and consolidation of the adjoining lungQUESTIONS Q1. What is the final diagnosis? Q2. What is the specific treatment for the disease? ANSWERS Amoebic liver abscess (ALA) with hepatopulmonary fistula The patient dramatically responded to injected metronidazole (500 mg thrice a day for 14 days) and tablet chloroquin (155 mg tablet; 2 tablets given twice a day for 2 days and then 1 tablet daily for 19 days). DISCUSSION ALA is a parasitic infestation caused by Entamoeba histolytica, mostly affecting young males.[1] Although seen all over the world, it is more prevalent and virulent in warm countries.[2] The diaphragmatic surface of the right lobe of the liver being the most common site, the abscess pierces through the adjoining diaphragm and ruptures into the right pleural space and the lung, leading to hepatopulmonary fistula.[3] The majority of patients present with fever, chest pain, cough, and dyspnoea. The pain is sharp and stabbing, felt in the lower chest, which worsens on deep breathing and coughing, thus resembling pleuritic pain. Due to predominant pulmonary symptoms, these cases are initially misdiagnosed as pneumonia.[3] The production of reddish brown (anchovy-sauce) sputum is pathognomonic of hepatopulmonary fistula.[1] On examination, patients are usually toxic, anemic, and tachypnoic. There is intercostal tenderness in the right lower chest and tender hepatomegaly. However, many a times, hepatomegaly may be missing as had happened in the present case.[4] There may be presence of edema overlying the ribs, costal margin, and anterior abdominal wall. Chest auscultation reveals pleural effusion, basal atelectasis, and pneumonitis.[3] Indirect hemagglutination (IHA) has a very high sensitivity rate for diagnosis of ALA.[2] Chest X-ray shows a raised right dome of the diaphragm, pleural effusions, and basal pneumonitis.[1] On ultrasound scan, ALA is seen as a hypo-echoic lesion that can be aspirated under ultrasound guidance. The aspirate has typical color and might show trophozoites under a microscope. CT scan is helpful in confirming the diagnosis of hepatopulmonary fistula. Management mainly consists of the anti-amoebic agent metronidazole that is active against the hepatic and intestinal phase of amoebiasis. The parenteral form of the drug is very effective in the treatment of pleuropulmonary and hepatic amoebiasis.[12] Chloroquin in addition is very useful since it gets concentrated in the liver. Nowadays, use of emetine hydrochloride is not recommended because of its myocardial toxicity.[1] If the abscess does not resolve with medical management, repeated ultrasound-guided needle aspiration of ALA or surgical drainage may be considered.[2]" @default.
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• W2008304859 date "2013-01-01" @default.
• W2008304859 modified "2023-09-26" @default.
• W2008304859 title "Young male presenting with features of pneumonitis" @default.
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• W2008304859 doi "https://doi.org/10.4103/1319-3767.108486" @default.
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