Thirty-two cases of hepatic amoebiasis with some unusual features are presented. The clinical spectrum and the value of investigations such as liver scanning, angiography and slide agglutination test are presented. Therapy is outlined.S. Afr. Med. J., 48, 1159 (1974

Horwitz, M.

Keeton, G.

Kottler, R.

Naidoo, P.M.

Stein, L.

English

AJOL - African Journals Online

3 June 1974 S.A. MEDICAL JOURNALHepatic AmoebiasisA STUDY OF 32 CASES IN THE WESTERN CAPE1159P. M. NAIDOO, G. KEETON, L. STEIN, R.KOTTLER, M.HORWITZSUMMARY TABLE I. MAIN CLINICAL FEATURES IN 32 CASES OFAMOEBIC LIVER ABSCESSThirty-two cases of hepatic amoebiasis with some unusualfeatures are presented. The clinical spectrum and thevalue of investigations such as liver scanning, angio-graphy and slide agglutination test are presented. Therapyis outlined.S. Air. Med. J., 48, 1159 (1974).Hepatic amoebiasis with its protean clinical manifestationspresents a diagnostic problem in endemic and non-endemic areas. The main differential diagnoses are hepa-toma, secondary metastases and hydatid disease. Of theseconditions, only amoebiasis responds to specific therapyIn our series 26 patients came from a particular geograph-ical locality in the Cape Peninsula, being farm labourersdrawn from a poor socio-economic group with poordietary intake and a suspicious water supply. These areimportant aspects in eradicating and preventing this disease.CasesPain 31Hepatomegaly 29~VM WLoss of weight 26Diarrhoea 21Anaemia 22Raised ESR ... 31Leucocytosis 21Hypo-albuminaemia 10Raised alk. phos. 13Raised SGOT 17Elevation of diaphragm 26Positive liver scan ... 22Anaemia Hb <11g; ESR averaqe 85 mm Westergren.Alkaline phosphatase >KA units; SGOT >30 IU.0/o97968781666797663141538191PATIENTSThe present study is based on 32 cases seen at SomersetHospital from 1969 to 1972. The following diagnosticcriteria were adopted: tender hepatomegaly; positive X-ray films; pus demonstrated by aspiration; positive liverscan; positive blood findings; response to specific therapy;and positive hepatic angiogram.The main clinical features are set out in Table I.DISCUSSIONDifferential DiagnosisThe main differential diagnosis in our series was fromprimary hepatoma. Loss of weight was a prominent symp-tom. One patient with extreme cachexia and massivehepatomegaly was referred as a primary hepatoma, butaspiration produced 2 litres of anchovy pus. Anotherpatient with malaise, loss of weight, hepatomegaly and aSomerset Hospital, Cape TownP. M. NAIDOO*G. KEETONL. STEINR. KOTTLERM. HORWITZDate received: 19 December 1973.'Present address and reprint requests: Livingstone Hospital, P.O. Korsten,Port Elizabeth.normal chest X-ray film, was initially diagnosed as hepa-toma. Liver scan showed multiple cold areas, and repeatedaspiration and biopsy procedures were negative. He deterio-rated despite specific therapy and developed a massiveright pleural effusion with a 'white out' on chest X-ray film.At autopsy a liver studded with amoebic abscesses wasfound, but the cause of the effusion was undetermined.These patients illustrate the problem of differentiatinghepatoma from liver abscess. In a situation like this anysuspicion that amoebiasis may be the cause should callfor aspiration of the liver.Liver Function and JaundiceWilmot' describes jaundice as a rare complication ofamoebiasis, but in this series 6 patients were jaundicedwith an average bilirubin of 3,9 mg/100 m!. The highincidence of abnormal liver function is also unusual.The following cases illustrate this problem.A 33-year-old sheep farmer presented with a historysuggestive of an amoebic abscess, and aspiration produced100 ml of anchovy pus. He became deeply jaundiced witha bilirubin of 12,1 mg/IOO ml, of which 11 mg/IOO mlwas conjugated. The alkaline phosphatase was 9,0 KAunits and the SOOT 98 ID. A further 500 ml pus wasaspirated and the jaundice subsided.A 45-year-old male presented with a typical history, andhepatomegaly with the bilirubin 1,9 mg/ 100 ml, alkalinephosphatase 46 KA units and SOOT 38 ID. Repeatedaspiration was negative. Liver scan showed 2 cold areas.1160 S.-A. MEDJESE TYDSKRIF S Junie 1974Hepatic angiography revealed 3 large well-circumscribedavascular areas. He improved with specific therapy anda repeat scan 6 months later proved a cure.PregnancyFive patients presented with amoebic liver abscessduring pregnancy and one was aspirated while in labour.This may be a chance association.Slide Agglutination TestThe slide agglutination test was posItIve in the 4 casesin which it was done. Its main value is the ease and rapidityof doing the test and a negative result in excluding thediagnosis. The only ·disadvantage is the cost involved.Radiological AspectsThe right hemidiaphragm was elevated in 26 patientsand the lateral film showed an anterior 'hump'.The liver scan showed 'cold areas' in 22 cases and puswas aspirated in 2 patients with normal scans.Hepatic angiography showed multiple abscesses in 2cases. This investigation is useful in differentiating hepa-t:>ma and abscess.PreventionIn the vast majority of our patients the clue to thediagnosis was their place of abode. If a patient with asuggestive history came from the area within the radiusof Vredenburg, Calvinia, Montagu and Cape Town,amoebiasis was usually diagnosed. Many factors couldbe analysed to explain this 'amoebic pocket', but thesepatients often drank water from rivers or water usedfor irrigation purposes.TreatmentDrugs: Metronidazole (Flagyl) 800 mg I.d.s. for 5 dayscured 16 patients. Emetine and chloroquine were admini-stered with Flagyl in 16 cases. No difference in response totreatment with the two regimens was noted.Aspiration: This was successful in 22 cases and theaverage yield of pus was 300 m!.The indications for aspiration were: (i) localised tender-ness intercostally or over a palpable hepar, swelling orbulging of ribs; (il) radiological elevation of the righthemidiaphragm; (iii) lack of response to specific treatmentand (il-) a left lobe abscess.REFERE ICEI. Wilmol. A. J. (1962): Clinical Amoebiasis. Oxford: Blackwell ScientificPublicationa. I..

Hepatic amoebiasis

Thirty-two cases of hepatic amoebiasis with some unusual features are presented. The clinical spectrum and the value of investigations such as liver scanning, angiography and slide agglutination test are presented. Therapy is outlined.S. Afr. Med. J., 48, 1159 (1974)

Hepatic amoebiasis

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