Amebic Liver Abcess in Nepal

To the Editor:

Amebic liver abscess (ALA) is the most common form of extraintestinal amebiasis, accounting for 3% to 9% of patients with amoebic infections. ^{1 –}3 It is always secondary to intestinal amebiasis that may be asymptomatic or may cause dysentery. In ALA-endemic countries where other modalities to confirm the diagnosis are not available, the diagnosis of ALA is based on clinical features, ultrasonographic findings, and a good response to treatment with metronidazole. ⁴ Ultrasound is the modality of choice for establishing the diagnosis and will detect almost 100% of abscesses. ⁵

I did a retrospective review at a large urban hospital in Nepal of all charts of patients with a hospital discharge diagnosis of ALA between January 1999 and December 2003. A total of 48 patients were diagnosed with ALA during the 5-year study period, but only 27 matched my diagnostic criteria, which were 1) at least 1 ALA clinical feature of fever, abdominal pain, or tenderness; 2) sonographic findings of space-occupying, round, hypoechoic liver lesions; and 3) good clinical response to treatment with metronidazole. Twenty-one patients with probable ALA were excluded from the analysis because they had already been treated with other antibiotics (eg, ciprofloxacin). Although very uncommon, diseases such as anaerobic pyogenic abscesses can present with these same features.

The period between 1999 and 2003 was chosen because it represented a time span during which our hospital had been recording file numbers of patients in a computer database, and more complete hospital records were available.

The mean age of the patients was 36.5 years (range 15–92 years). Male-to-female ratio was 4.4:1. The most common signs and symptoms on the day of admission (Table) were fever (93%), right upper quadrant tenderness (100%), and hepatomegaly (93%). The median hematocrit was 32% (range 17%–42%) and the total white blood cell count was 14 200 cells/μL (range 5000–30 500 cells/μL). Elevation of the right hemidiaphragm, right-sided pleural effusions, and right lower lobe consolidation were common abnormalities seen on chest radiographs. The abscesses detected were solitary in

Symptoms, clinical findings, radiological findings, oral vs oral or parenteral treatment, and extrahepatic amebiasis in 27 patients with amebic liver abscess discharged from an urban hospital in Nepal between January 1999 and December 2003

66.67% (18 of 27) and restricted to the right lobe in 85.18% (23 of 27). Seven patients had 2 abscesses and 2 patients had 3 abscesses. In 3 patients, abscesses were located in both lobes, whereas only 1 patient (3.7%) had an isolated abscess in the left lobe. Fourteen patients (51.9%) underwent aspiration and drainage of their abscesses. However, none of the aspirated pus showed ameba or growth of any bacteria. Twenty-three (85.18%) of the patients with ALA were treated with oral metronidazole, whereas only 4 patients (14.81%) required both intravenous and oral metronidazole. The mean hospital stay was 3.7 days (range 1–14 days). Thirteen patients (48.14%) developed extrahepatic involvement with pleuro-pulmonary involvement predominating (44.44%). We encountered 1 patient with peritoneal involvement, but this patient was managed with percutaneous drainage and medical treatment.

In conclusion, I found that the epidemiology of ALA at my institution is not different from that found elsewhere in the world. It is interesting to note that ALA is not always solitary. About one third of the patients with ALA had multiple abscesses in my series.