El absceso hepático amebiano puede ser una enfermedad emergente en España a causa de la inmigración y los viajes a países endémicos. Su tratamiento. Ciencias Médicas. Enero-febrero, ; 19(1): Absceso hepático amebiano, presentación atípica. An atypical presentation of amoebic hepatic abscess. Hepatic abscesses, like abscesses elsewhere, are localised collections of necrotic inflammatory tissue caused by bacterial, parasitic or fungal agents.
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Amebic liver abscess with bacterial superinfection in a patient with no epidemiologic risk factors. Salto amibiqnoR. Service of Digestive Diseases. Hospital Universitario 12 de Octubre.
Absceso hepatico amebiano.
The amebic liver abscess is uncommon in developed countries like Spain, but the incidence is increasing probably due to the migratory movements of the population. We report a case of an amebic abscess, initially unsuspected due to the absence of epidemiologic risk factors and the negative serology for amebiasis, in the early stages of the disease.
Rev Esp Enferm Dig ; Departamento de Medicina Aparato Digestivo. The amebic liver abscess ALA has a worldwide incidence of 50 cases per year 1. In developing countries like Vietnam, were infection by Entamoeba histolytica is endemic, the annual incidence of amebic liver abscess is 21 cases perhabitants.
In developed countries such as the United States, it is unusual and is most commonly seen in immigrants from and travelers to developing countries 2. It has also been reported in imunosuppressed patients, HIV patients, patients on corticosteroids or suffering from chronic infections like tuberculosis or syphilis and patients who have undergone post-traumatic splenectomy.
Entamoeba histolytica is a protozoa that infects humans by fecal-oral contact. It usually inhabits the colon, where it can cause an asymptomatic infection or it can become invasive and cause amebic colitis. After invasion into the intestinal mucosa, it can disseminate to other organs, predominantly the liver, leading to an amebic abscess.
The epidemiology in Spain is unknown.
There are small series of cases and isolated cases described in the literature Some of these cases lacked history of exposure and happened in groups at risk or were considered autochthonous, as the case that we report, that developed on the amlbiano of hepatitis B surface antigen HBsAg carrier, with no other factors associated. Asymptomatic carrier of hepatitis B surface antigen HBsAgwith normal liver profile.
He denied having travelled abroad or any contact with immigrants from developing countries. He did not take any medication. He was admitted to our hospital with a 5-day history of dull and continuous abdominal pain in epigastrium and mesogastrium, sweating, chills and a temperature of up to 39ordm;ordm; C.
He denied respiratory symptoms or changes in bowel habit. On admission, the temperature was 39ordm; C, his abdomen was tender in the right upper quadrant, with voluntary guarding but negative Murphy and Blumberg signs. Acbeso ultrasonography and computed tomography showed a hypodense collection, 7,5 x 5 cm in diameter, in segment II of the left lobe of the liver, heterogeneous and with rim enhancement, protruding from the liver surface. There were also radiologic findings of chronic liver disease without portal hypertension Fig 1.
A diagnosis of pyogenic abscess was initially entertained, due to the absence of epidemiologic risk factors and the negative serology for Entamoeba histolytica.
Antibiotic therapy was initiated with piperaciline-tazobactam and a percutaneous drainage was performed.
Absceso hepático amebiano sobreinfectado sin antecedentes epidemiológicos
Aspirate from the abscess was thick in consistency and reddish, “chocolate” coloured, with negative microscopic examination for organisms. A sample of the aspirate was cultured. The agceso pain improved, but the patient remained with high temperature. The antibiotic regimen was changed to imipenem. The diagnosis of ALA was confirmed after identifying motile forms of Entamoeba histolytica in the liver aspirate, with negative culture for bacteria Fig.
Treatment with metronidazole was initiated with disappearance of fever. The patient remained afebrile for 48 heepatico with subsequent recurrence of the high temperature. A second blood cultures were sterile. Piperaciline-tazobactam was added, with resolution of fever and marked improvement in the patientacute;s condition.
There was no need for a second percutaneous drainage. The patient was discharged with levofloxacin for six weeks and radiologic studies obtained one month after discontinuation of antibiotic, showed decrease in the size of the abscess. The ALA is uncommon in developed countries abceao Spain in the absence of an epidemiologic history of exposure, such as travelling to endemic countries, contacting with immigrants from regions of endemicity, or belonging to a risk groups.
A case of a HBsAg carrier with simultaneous amebic liver abscess has been reported in an area of endemicity for amebiasis hhepatico on the background nepatico hepatitis E infection The case that we describe could be considered an autochthonous case of ALA, related to the increasing number of cases diagnosed in Spain. The Sbceso is most common in men and usually locates in the right lobe of the liver. The microbiologic diagnosis is based on the detection of the parasite in the abscess aspirate, although this is an uncommon finding due to the necrotic nature of the abscess The lack of findings consistent with pyogenic abscess negative gram staining and culture leads to the diagnosis of amebic abscess.
Inmunología del absceso hepático amebiano
Diagnostic percutaneous aspiration is rarely needed. In the case that we report the percutaneous aspiration was required because of false negative serology for amebiasis and the abveso of epidemiologic risk factors.
Serum tests are usually very helpful in the diagnosis of the disease. The sensitivity increases in the second to third week of the infection.
In the present case, the early determination, in the sixth day of the disease, could be the cause of the initial negative result. There is often leukocytosis and abnormal liver profile. The radiological findings are those of a liver abscess and consist of a low density collection on CT or a hypoechogenic lesion on ultrasonography, with posterior acustic shadowing and inner echos that mobilize with postural changes. Nevertheless, there are no pathognomonic findings for ALA 2.
Gammagraphy with gallium reveal “cold” lesions with peripheral rim enhancement, unlike in the case of a pyogenic abscess that appear as a capturing lesion.
Nevertheless, this technique lacks the specificity that was initially believed The complications of ALA are: The risk of rupture is higher in left-lobe abscesses, due to the smaller size of this lobe and the lack of space for a growing mass 2. The aim of the treatment is to treat invasive liver infection and eradicate colonic colonization. Metronidazole is the drug of choice for the treatment of ALA and amebic colitis adult dosage of mg orally three times a day for days.
This therapeutic regimen should be followed by a luminar agent like paramomycin for a period of seven days 2. Most ALA respond to metronidazole therapy.
The percutaneous aspiration and drainage of ALA is controversial. Indications for aspiration of liver abscesses are the need to rule out a pyogenic abscess; bacterial coinfection of ALA, large abscesses with a diameter of more than 5 cm, the prevention of rupture of left-lobe abscesses, the failure to respond clinically to drug therapy within 5 to 7 days and the threat of imminent rupture 2,15, The percutaneous aspiration can cause the superinfection of the ALA, so it should be avoided in those cases with no indication.
This is probably what happened in our case, when the negative serology associated to the absence of epidemiologic risk factors misled to the diagnosis of pyogenic abscess, and subsequently, an early percutaneous drainage was performed.
Surgical treatment should be reserved for instances of rupture of the abscess or coinfection that is not solved with medical treatment 2, The increase of the number of cases in the absence of epidemiologic risk factors in our country, as derived from the increasing number of cases lately reported, and the present case, lead to consider the existence of autochthonous cases. The possibility of ALA should be entertained even in the absence of history of exposure, and serology should be repeated in suspected cases with an initially negative result.
An early and accurate diagnosis avoids a higher morbi-mortality, as the treatment for ALA differs from that of the pyogenic abscess. It would be convenient to design epidemiologic studies to know the real prevalence of amebiasis in Spain. Diagnosis and management of amebiasis.
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HBs Ag carrier with simultaneous amebic liver absceso and acute hepatitis E. Ind J Gastroenterol ; Li E, Stanley SL.
Gastroenterol Clin North Am ; Evaluation of a new bicolores latex agglutination test for immunological diagnosis of hepatic amebiasis. J Clin Microbiol ; Med Clin ; Gastroenterol Hepatol ;