|Year : 2013 | Volume
| Issue : 1 | Page : 89-91
Amebic liver abscess and polycystic liver disease
Karan V. S. Rana, Trupti Tonape, Bharat B Dogra, Srihari Sridharan
Department of General Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India
|Date of Web Publication||14-Mar-2013|
Department of General Surgery, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
Source of Support: None, Conflict of Interest: None
Polycystic liver disease is a rare disorder which remains asymptomatic. Infection of cyst is a major complication and is usually pyogenic. We report a rare case of amebic liver abscess in a patient with polycystic liver disease. In our search we found one such case report. Clinical features and radiological findings are usually sufficient, but atypical history and the presence of multiple hepatic abscesses in CT scan delayed diagnosis in our case. Histopathology of the cyst wall and enzyme immunoassay asserted the diagnosis.
Keywords: Amebic liver abscess, extra-intestinal amebiasis, polycystic liver disease
|How to cite this article:|
Rana KV, Tonape T, Dogra BB, Sridharan S. Amebic liver abscess and polycystic liver disease. Med J DY Patil Univ 2013;6:89-91
| Introduction|| |
Adult polycystic liver disease (PCLD), is a rare (incidence < 0.01%) dominantly inherited autosomal disorder.  In the absence of complications, PCLD remains asymptomatic throughout the life. Infection of cyst is usually pyogenic. We report a rare case of amebic liver abscess (ALA) in a polycystic liver. Clinical presentation and radiological appearance make ALA a diagnosis of ultrasonography. However, the picture is altered in polycystic liver disease.
| Case Study|| |
A 75-year-old male presented with complaints of bleeding per rectum and pain in the right upper quadrant of the abdomen for 48 hrs. There was no history of fever or jaundice. Abdominal examination revealed tender hepatomegaly and digital rectal examination showed blood and mucus. Chest examination showed reduced air entry in the right lower zone. General examination showed anemia and pitting edema in both lower limbs. Investigations revealed hemoglobin of 7gm/dL, leucocytosis and normal liver function tests. Proctoscopy showed hyperemic mucosa. Sigmoidoscopy revealed a 2 × 1 cm punched out ulcer and multiple tiny ulcers. After a course of metronidazole (800 mg tid for 5 days), the bleeding stopped and repeat colonoscopy was normal. Abdominal ultrasonography revealed multiple hepatic cysts, largest measuring 18 × 17 × 10 cm with hepatomegaly (21 cm) and simple left renal cyst (3 × 3 cm). Computed tomography reported multiple hepatic abscesses, with possibility of rupture in subcapsular space and largest lesion pressing on right branch of portal vein, IVC and head of pancreas [Figure 1] with simple cyst of left kidney, mild rectal wall thickening and bilateral basal pleural effusion. Pleurocentesis showed transudative effusion.2D ECHO showed diastolic dysfunction, MRII, ARI.
|Figure 1: CT scan showing multiple cysts in liver with mass effect on right branch of portal vein, IVC and head of pancreas|
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After the correction of anemia, laparotomy was done. It revealed a large cyst covering almost the entire right lobe of liver. The cyst contained yellow-colored fluid [Figure 2]. Drainage of the cyst, partial excision of cystwall and omentopexy were done. Histopatholgical examination of the cystwall showed fibrocollagenous wall lined by granulation tissue, marked lymphoplasmocytic cells infiltration, few large cells with foamy cytoplasm containing RBCs. PAS stain highlighted the trophozoites of ameba. Enzyme immunoassay of antibodies to Entamoeba histolytica showed value of 2.57 OD units [positive >0.4 OD units]. The patient was treated with intravenous metronidazole (500 mg qid for 10 days) and showed improvement. CT scan after 8 months [Figure 3] revealed multiple cysts in both lobes of liver, largest measuring 2.4 cm in size and the patient is asymptomatic till date.
|Figure 2: Intraoperative picture showing the content of the cyst and the cyst wall|
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|Figure 3: CT scan after 8 months showing multiple cysts in both lobes of liver largest measuring 2.4 cm in size|
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| Discussion|| |
The patient discussed in this case report comes from an endemic area for amebiasis. Amebiasis starts with the ingestion of the quadrinucleate cyst of E. histolytica from fecally contaminated food or water. After reaching the intestine, excystation releases trophozoites that invade the intestinal mucosa and activate inflammatory response. This gives rise to symptoms of severe ulcerative proctocolitis, like blood-stained mucus stools. This was one of the presenting symptoms in our patient.
In this case, metronidazole helped in dealing with ulcers and bleeding but the lesion in the liver was not regressing in size. The ambiguity of radiological investigations and the pressure effects of the cyst on IVC demanded surgery. The largest cyst compressing adjacent structures was identified. Drainage of the cyst, partial excision of cyst wall and omentopexy were done. The cyst wall was sent for pathologist review and PAS stain highlighted the trophozoites of ameba. This histopathological report leads to diagnosis of ALA. The incidence of ALA in cases of amebiasis varies between 3 and 9%.  This occurs due to the portal circulation and if left untreated can cause life-threatening complications.
The microscopic examination of the fluid from the cyst showed no neutrophils and yielded no growth on culture. This finding rules out pyogenic abscess.  Serological testing was done later to endorse the histopathological diagnosis of ALA.
The radiological finding of multiple hepatic cysts and a simple renal cyst indicates the aetiology of polycystic liver disease. PCLD was first described by Bristowe in 1856. It is linked to a mutation on chromosome 19 that leads to a mutated protein hepatocystin which may play a role in abnormal biliary cell proliferation and differentiation.  Akin to our patient, cases of PCLD with few renal cysts have been reported.  PCLD is usually underdiagnosed and symptoms depend on the size of the largest cyst. Complications like cyst hemorrhage, infection, portal hypertension and IVC compression make the condition symptomatic. Infection of cyst when seen is usually pyogenic , but this is ruled out in this patient with the clinical picture and sterile nature of the aspirate. Aspiration of the cyst, fenestration, hepatic resection or liver transplantation should help in case of complications. 
The patient was evaluated after 8 months and was asymptomatic then. CT scan was repeated which showed presence of multiple hepatic cysts [Figure 3], confirming PCLD. There exists a higher prevalence of mitral valve abnormalities in patients with PCLD.  which was true in our case also (mitral regurgitation II/IV).
It is common to encounter cases of ALA, especially in endemic areas. It is usually diagnosed fast and treated with good results. However this case necessitated surgical intervention due to large size of the cyst. One case of ALA in polycystic disease is reported so far. 
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[Figure 1], [Figure 2], [Figure 3]