UT Health San Antonio San Antonio, TX, United States
Eugene Stolow, MD, MPH, Brenda Briones, MD, Jacob Ritter, MD, Patrick Snyder, MD UT Health San Antonio, San Antonio, TX
Introduction: Entamoeba histolytica infection is often limited to the intestine but can have extraintestinal manifestations such as amebic liver abscess (ALA). Hepatic vein and inferior vena cava (IVC) thrombosis, or Budd-Chiari Syndrome (BCS), is an exceedingly rare complication of ALA caused by mechanical compression and inflammation. We present a case of amebiasis leading to secondary BCS.
Case Description/Methods: A 35-year-old Burmese man with no past medical history presented to the ED with 2 weeks of malaise and right upper quadrant pain. He was febrile and tachycardic with labs showing leukocytosis and elevated liver enzymes and inflammatory markers. Abdominopelvic CT demonstrated a 2.6 cm rim-enhancing liver abscess, thrombosis in the hepatic vein and IVC extending into the right atrium, and ascending colon wall thickening. Serum antibodies to E. histolytica were detected, with trophozoites seen on stool microscopy. Percutaneous liver abscess aspiration yielded 3 mL of pasty fluid. Cytology revealed acute inflammatory cells, but cultures were negative. Colonoscopy showed patchy, erythematous mucosa in the cecum extending into the ascending colon. Histology did not demonstrate trophozoites. A hypercoagulability workup, including JAK2 mutations, was negative. He was discharged on metronidazole, levofloxacin, paromomycin, and warfarin with complete symptom resolution reported on subsequent encounter.
Discussion: Amebiasis occurs most frequently in developing countries with poor sanitation, reduced access to medical care and poor socioeconomic conditions. Its non-specific clinical and diagnostic findings, along with the possibility of falsely negative serologic tests in the first 7 days of infection and the inherent difficulty of identifying trophozoites histologically, often contribute to delayed or missed diagnosis. Imaging and colonoscopy in intestinal amebiasis can show evidence of right sided colitis, mimicking other colitides such as Yersinia, typhlitis, Mycobacterium tuberculosis and Crohn’s disease. Treatment includes a tissue agent and a luminal agent. Liver abscess drainage can be considered for large abscesses, those not responding to medical therapy and in cases with an unclear diagnosis. In secondary BCS, treatment of the underlying condition is vital. While clear guidelines for anticoagulation in this setting are lacking, failure to initiate treatment can increase risk for ascites, liver failure or fatal pulmonary embolism.
Figure: Image 1.
1(a): Sagittal abdominopelvic computed tomography image demonstrating extensive suprahepatic inferior vena cava (IVC) thrombosis and a 4.5 x 2.5 cm thrombus in the right atrium
1(b): Cytology specimen of the liver abscess fluid. Romanowsky stain. 40x. Predominantly necrotic/degenerating cellular debris and many neutrophils
1(c): Colon. H&E. 10x: Active chronic colitis with focal surface ulceration
1(d): Colonoscopy demonstrating mild to moderate inflammatory changes of the cecum and ascending colon
Disclosures: Eugene Stolow indicated no relevant financial relationships. Brenda Briones indicated no relevant financial relationships. Jacob Ritter indicated no relevant financial relationships. Patrick Snyder indicated no relevant financial relationships.
Eugene Stolow, MD, MPH, Brenda Briones, MD, Jacob Ritter, MD, Patrick Snyder, MD. P2919 - Budd-Chiari Syndrome Secondary to an Amebic Liver Abscess, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
