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Amoebic hepatic and renal abscesses complicating amoebic colitis
Clinics and Research in Hepatology and Gastroenterology (2014) 38, 541—542
Available online at
ScienceDirect www.sciencedirect.com
IMAGE OF THE MONTH
Amoebic hepatic and renal abscesses complicating amoebic colitis Najat Mourra a, Nikias Colignon b, Chloé Broudin a, Lionel Arrivé b,∗ a
Department of Pathology, Hospital Saint-Antoine, AP—HP, Université Pierre et Marie Curie, Paris, France Department of Radiology, Hospital Saint-Antoine, AP—HP, Université Pierre et Marie Curie, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
b
Available online 19 June 2014
A 55-year-old man of African origin (Mali), living in France for 33 years but regularly returning back home, was referred to our hospital for a persistent sceptic choc, six days after right colectomy for a presumed diagnosis of colonic tumor. Three weeks earlier, he was admitted in a district hospital for anemia (6 g/dL), weight loss (20 kilos in 3 months) and melena. Upper GI endoscopy, performed after blood transfusion, showed no abnormalities. Lower endoscopy was not performed because of a suspicion of fistula between the right colon and retroperitoneum. A CT scan demonstrated a renal abscess communicating with right colon and a large liver abscess (Fig. 1). A right nephrectomy, cholecystectomy and liver abscess drainage were performed. Cross-cut of nephrectomy specimen demonstrated multiple yellow-green abscesses foci (Fig. 2a). Microscopic examination of renal abscesses showed necrotic areas with acute inflammatory infiltrates and pathognomonic feature of Entamoeba histolytica. Trophozoites have an irregular outline with a foamy cytoplasm
∗
Corresponding author. Tel.: +0149282257; fax: +0149282259. E-mail address: [email protected] (L. Arrivé).
http://dx.doi.org/10.1016/j.clinre.2014.04.007 2210-7401/© 2014 Elsevier Masson SAS. All rights reserved.
and a spherical nucleus with a tiny central karyosome (Fig. 2b). Colonic slides were re-examined in our laboratory and numerous trophozoites were also present in colonic abscess. Amoebic serology proved positive and the patient was treated intravenously with metronidazole (1 g/24 h/30 days). Despite this adapted treatment against visceral amoebiasis, associated with broad-spectrum antibiotics, his medical condition continued to deteriorate. Further serology for other infectious aetiology was sought. Serological tests for HIV, viral hepatitis, and Epstein-Barr virus were negative, but aspergillus test was positive. Aspergillus hyphae were found in bronchial aspiration, and CT scan revealed typical features of invasive aspergillosis. The patient received voriconazole intravenously for 45 days and he was discharged from intensive care unit after 3 months. E. histolytica is an intestinal protozoan parasite that causes invasive amoebiasis in 40—50 million people, resulting in 40,000—100,000 deaths worldwide each year. E. histolytica infection can range from asymptomatic infection (in most cases) to invasive disease, such as amoebic colitis or life threatening abscess of the visceral organs [1,2]. The two main clinical syndromes of invasive amoebiasis are amoebic colitis and amoebic liver abscess, which can
542
Figure 1 CT scan. a. CT scan demonstrates communication (arrows) between renal abscess (A) and right colon (C). b. Large liver abscess (A) is well demonstrated. Other abscesses (arrows) are also well seen.
be accompanied by pleural effusion, empyema, intestinal perforation, and peritonitis. Clinical presentations include fever, diarrhoea, right upper quadrant pain, and dysentery [1,2]. Metastatic hepatic abscesses occur when amoebae reach the liver in the portal vein from the gut. This condition may be indistinguishable, as in our patient, from colonic cancer with malignant secondary deposits in the liver. Amoebic serology and colonic biopsies clarify the diagnosis [1,2]. Kidney involvement is very rare; it is the fifth most common site for amoebic abscess [3]. Metronidazole remains the mainstay of treatment for amoebic colitis and liver abscess. Surgical drainage is considered only if there is no response to drug therapy, or when the diagnosis is uncertain [1,2]. Although rare in many parts of the world, amoebiasis should be included in the differential diagnoses of acute abdomen and colonic, liver and even renal masses, especially in people coming from endemic areas. A high index of
N. Mourra et al.
Figure 2 Pathologic study. a. Cross-cut of nephrectomy specimen shows multiple yellow-green abscess foci. b. Trophozoites having an irregular outline with a foamy cytoplasm and a spherical nucleus (Hematoxylin-Eosin, original magnification × 400).
suspicion is crucial to avoid unnecessary surgery and complication with other opportunistic, sometimes fatal, infections.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Haque R, Huston CD, Hughes M, et al. Amebiasis. N Engl J Med 2003;348:1565—73. [2] Stanley Jr SL. Amoebiasis. Lancet 2003;361:1025—34. [3] Brandt H, Tamayo RP. Pathology of human amebiasis. Hum Pathol 1970;1:351—85.
Available online at
ScienceDirect www.sciencedirect.com
IMAGE OF THE MONTH
Amoebic hepatic and renal abscesses complicating amoebic colitis Najat Mourra a, Nikias Colignon b, Chloé Broudin a, Lionel Arrivé b,∗ a
Department of Pathology, Hospital Saint-Antoine, AP—HP, Université Pierre et Marie Curie, Paris, France Department of Radiology, Hospital Saint-Antoine, AP—HP, Université Pierre et Marie Curie, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
b
Available online 19 June 2014
A 55-year-old man of African origin (Mali), living in France for 33 years but regularly returning back home, was referred to our hospital for a persistent sceptic choc, six days after right colectomy for a presumed diagnosis of colonic tumor. Three weeks earlier, he was admitted in a district hospital for anemia (6 g/dL), weight loss (20 kilos in 3 months) and melena. Upper GI endoscopy, performed after blood transfusion, showed no abnormalities. Lower endoscopy was not performed because of a suspicion of fistula between the right colon and retroperitoneum. A CT scan demonstrated a renal abscess communicating with right colon and a large liver abscess (Fig. 1). A right nephrectomy, cholecystectomy and liver abscess drainage were performed. Cross-cut of nephrectomy specimen demonstrated multiple yellow-green abscesses foci (Fig. 2a). Microscopic examination of renal abscesses showed necrotic areas with acute inflammatory infiltrates and pathognomonic feature of Entamoeba histolytica. Trophozoites have an irregular outline with a foamy cytoplasm
∗
Corresponding author. Tel.: +0149282257; fax: +0149282259. E-mail address: [email protected] (L. Arrivé).
http://dx.doi.org/10.1016/j.clinre.2014.04.007 2210-7401/© 2014 Elsevier Masson SAS. All rights reserved.
and a spherical nucleus with a tiny central karyosome (Fig. 2b). Colonic slides were re-examined in our laboratory and numerous trophozoites were also present in colonic abscess. Amoebic serology proved positive and the patient was treated intravenously with metronidazole (1 g/24 h/30 days). Despite this adapted treatment against visceral amoebiasis, associated with broad-spectrum antibiotics, his medical condition continued to deteriorate. Further serology for other infectious aetiology was sought. Serological tests for HIV, viral hepatitis, and Epstein-Barr virus were negative, but aspergillus test was positive. Aspergillus hyphae were found in bronchial aspiration, and CT scan revealed typical features of invasive aspergillosis. The patient received voriconazole intravenously for 45 days and he was discharged from intensive care unit after 3 months. E. histolytica is an intestinal protozoan parasite that causes invasive amoebiasis in 40—50 million people, resulting in 40,000—100,000 deaths worldwide each year. E. histolytica infection can range from asymptomatic infection (in most cases) to invasive disease, such as amoebic colitis or life threatening abscess of the visceral organs [1,2]. The two main clinical syndromes of invasive amoebiasis are amoebic colitis and amoebic liver abscess, which can
542
Figure 1 CT scan. a. CT scan demonstrates communication (arrows) between renal abscess (A) and right colon (C). b. Large liver abscess (A) is well demonstrated. Other abscesses (arrows) are also well seen.
be accompanied by pleural effusion, empyema, intestinal perforation, and peritonitis. Clinical presentations include fever, diarrhoea, right upper quadrant pain, and dysentery [1,2]. Metastatic hepatic abscesses occur when amoebae reach the liver in the portal vein from the gut. This condition may be indistinguishable, as in our patient, from colonic cancer with malignant secondary deposits in the liver. Amoebic serology and colonic biopsies clarify the diagnosis [1,2]. Kidney involvement is very rare; it is the fifth most common site for amoebic abscess [3]. Metronidazole remains the mainstay of treatment for amoebic colitis and liver abscess. Surgical drainage is considered only if there is no response to drug therapy, or when the diagnosis is uncertain [1,2]. Although rare in many parts of the world, amoebiasis should be included in the differential diagnoses of acute abdomen and colonic, liver and even renal masses, especially in people coming from endemic areas. A high index of
N. Mourra et al.
Figure 2 Pathologic study. a. Cross-cut of nephrectomy specimen shows multiple yellow-green abscess foci. b. Trophozoites having an irregular outline with a foamy cytoplasm and a spherical nucleus (Hematoxylin-Eosin, original magnification × 400).
suspicion is crucial to avoid unnecessary surgery and complication with other opportunistic, sometimes fatal, infections.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Haque R, Huston CD, Hughes M, et al. Amebiasis. N Engl J Med 2003;348:1565—73. [2] Stanley Jr SL. Amoebiasis. Lancet 2003;361:1025—34. [3] Brandt H, Tamayo RP. Pathology of human amebiasis. Hum Pathol 1970;1:351—85.