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Fulminant necrotizing amoebic colitis
Travel Medicine and Infectious Disease (2012) 10, 270e271
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
Fulminant necrotizing amoebic colitis Ankur Arora a, Sonia Sandip, Amar Mukund*, Yashwant Patidar Department of Radiology, Institute of Liver & Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India Received 14 March 2012; received in revised form 22 March 2012; accepted 26 March 2012 Available online 26 May 2012
KEYWORDS Fulminant; Amoebic; Colitis
Summary The emergence of amoebiasis is of great public health concern since it has the potential to become endemic in developed nations essentially due to increased travel to endemic areas, emigration of people from affected nations and increase in the HIVeAIDS population. Fulminant necrotizing amoebic colitis is a rare and relatively less-known form of amoebiasis typically associated with very high morbidity and mortality, as is presented in the current case. ª 2012 Elsevier Ltd. All rights reserved.
A 54-year old male presented with fever of two weeks duration with worsening right upper-quadrant pain. The laboratory test results were: haemoglobin 10.1 g/dL; leukocyte count 31,000 cells/mm3 (neutrophils 83%); total bilirubin 2.4 mg/dL; serum aspartate amino transferase (SGOT) 105 IU/L; serum alanine amino transferase (SGPT) 76 IU/L and alkaline phosphatase 385 IU/L. Imaging revealed a large liver abscess with impending rupture for which catheter drainage was performed (Fig. 1A,B). Amoebic serology using enzyme linked immunosorbent assay (ELISA) yielded very high antibody titres and in spite of initiating intravenous anti-amoebic
* Corresponding author. Tel.: þ91 9540950974; fax: þ91 11 26123504. E-mail addresses: [email protected] (A. Arora), [email protected] (S. Sandip), [email protected] (A. Mukund), [email protected] (Y. Patidar). a Tel.: þ91 9873030114; fax: þ91 11 23411385.
drugs (metronidazole) the patient deteriorated and exhibited signs of bowel perforation (Fig. 2A,B). Emergency laparotomy confirmed caecal and rectal perforation and the patient subsequently succumbed to septicaemia and hypotension. Fulminant necrotizing amoebic colitis is a rare complication of intestinal amoebiasis with limited case reports in the literature.1,2 It represents an aggressive necrotizing response of the colon to the protozoan (Entamoeba histolytica) resulting in perforation, peritonitis, and finally death (reported mortality ranges from 55 to 87.5%). Significant factors believed to be associated with the development of fulminant necrotizing amoebic colitis include male gender, more than 60 years of age, presence of concomitant liver abscess, escalating abdominal pain, signs of peritonitis, leukocytosis, hyponatremia, hypokalemia and hypoalbuminemia.1 The preferred treatment includes primary total resection of involved segment and exteriorization of the proximal and distal transected ends, and bowel reconstruction 3e6 months later.1,2
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.009
A. Arora et al.
Figure 1 Plain radiograph (A) and axial unenhanced CT scan (B) of abdomen post catheter drainage of the large liver abscess.
271
Figure 2 Follow-up CT-scannogram following rapid clinical deterioration reveals gross pneumoperitoneum (A). Axial CT sections show colonic wall thickening with extra-luminal air (B).
References Conflict of interest The manuscript has not been submitted to any other journal and is original work of the authors and there is no financial disclosure to be made. The final manuscript has been seen and approved by all authors.
1. Gupta SS, Singh O, Shukla S, Raj MK. Acute fulminant necrotizing amoebic colitis: a rare and fatal complication of amoebiasis: a case report. Cases J 2009 Sep 11;2:6557. 2. Ozdogan M, Baykal A, Aran O. Amebic perforation of the colon: rare and frequently fatal complication. World J Surg 2004 Sep; 28(9):926e9.
Available online at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CASE REPORT
Fulminant necrotizing amoebic colitis Ankur Arora a, Sonia Sandip, Amar Mukund*, Yashwant Patidar Department of Radiology, Institute of Liver & Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India Received 14 March 2012; received in revised form 22 March 2012; accepted 26 March 2012 Available online 26 May 2012
KEYWORDS Fulminant; Amoebic; Colitis
Summary The emergence of amoebiasis is of great public health concern since it has the potential to become endemic in developed nations essentially due to increased travel to endemic areas, emigration of people from affected nations and increase in the HIVeAIDS population. Fulminant necrotizing amoebic colitis is a rare and relatively less-known form of amoebiasis typically associated with very high morbidity and mortality, as is presented in the current case. ª 2012 Elsevier Ltd. All rights reserved.
A 54-year old male presented with fever of two weeks duration with worsening right upper-quadrant pain. The laboratory test results were: haemoglobin 10.1 g/dL; leukocyte count 31,000 cells/mm3 (neutrophils 83%); total bilirubin 2.4 mg/dL; serum aspartate amino transferase (SGOT) 105 IU/L; serum alanine amino transferase (SGPT) 76 IU/L and alkaline phosphatase 385 IU/L. Imaging revealed a large liver abscess with impending rupture for which catheter drainage was performed (Fig. 1A,B). Amoebic serology using enzyme linked immunosorbent assay (ELISA) yielded very high antibody titres and in spite of initiating intravenous anti-amoebic
* Corresponding author. Tel.: þ91 9540950974; fax: þ91 11 26123504. E-mail addresses: [email protected] (A. Arora), [email protected] (S. Sandip), [email protected] (A. Mukund), [email protected] (Y. Patidar). a Tel.: þ91 9873030114; fax: þ91 11 23411385.
drugs (metronidazole) the patient deteriorated and exhibited signs of bowel perforation (Fig. 2A,B). Emergency laparotomy confirmed caecal and rectal perforation and the patient subsequently succumbed to septicaemia and hypotension. Fulminant necrotizing amoebic colitis is a rare complication of intestinal amoebiasis with limited case reports in the literature.1,2 It represents an aggressive necrotizing response of the colon to the protozoan (Entamoeba histolytica) resulting in perforation, peritonitis, and finally death (reported mortality ranges from 55 to 87.5%). Significant factors believed to be associated with the development of fulminant necrotizing amoebic colitis include male gender, more than 60 years of age, presence of concomitant liver abscess, escalating abdominal pain, signs of peritonitis, leukocytosis, hyponatremia, hypokalemia and hypoalbuminemia.1 The preferred treatment includes primary total resection of involved segment and exteriorization of the proximal and distal transected ends, and bowel reconstruction 3e6 months later.1,2
1477-8939/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2012.03.009
A. Arora et al.
Figure 1 Plain radiograph (A) and axial unenhanced CT scan (B) of abdomen post catheter drainage of the large liver abscess.
271
Figure 2 Follow-up CT-scannogram following rapid clinical deterioration reveals gross pneumoperitoneum (A). Axial CT sections show colonic wall thickening with extra-luminal air (B).
References Conflict of interest The manuscript has not been submitted to any other journal and is original work of the authors and there is no financial disclosure to be made. The final manuscript has been seen and approved by all authors.
1. Gupta SS, Singh O, Shukla S, Raj MK. Acute fulminant necrotizing amoebic colitis: a rare and fatal complication of amoebiasis: a case report. Cases J 2009 Sep 11;2:6557. 2. Ozdogan M, Baykal A, Aran O. Amebic perforation of the colon: rare and frequently fatal complication. World J Surg 2004 Sep; 28(9):926e9.