2507 Amoebic Liver Abscess With Synchronous Proctitis—Presenting With Massive Lower Gastrointestinal Bleeding: A Case Report of a Rare Presentation of Amebiasis

Abstract

INTRODUCTION: Amoebic colitis and liver abscess caused by Entamoeba histolytica is one of the most important enteropathogen, leading to 40-73 per 100,000 deaths annually worldwide.1,2 Transmission generally occurs by fecal-oral route and during male homosexual activity.3 Colonic involvement was seen in 58% patients with amoebic liver abscess, but only 7% presents with diarrhea and bleeding.4 CASE DESCRIPTION/METHODS: A 25-year-old MSM patient with newly diagnosed HIV infection had persistent low grade fever and diarrhea 3-4 times/day for 1 month. He sometimes noticed a small amount of fresh blood in the stool and had mild epigastric discomfort for 1 week. He had worsening abdominal pain, radiating to back and passed 1000 mL fresh blood per rectum. Physical examination showed fever (38.9oC), pallor and markedly enlarged liver with tenderness. Lab showed hemoglobin 6.1 g/dl, white blood cell count 25350 cell/ul (N 89%, L 4%, M 7%), total/direct bilirubin 1.8/1.1 mg/dL, SGOT/SGPT 353/111 U/L, albumin/globulin 2.7/6.6 g/dL, ALP 436 U/L. Colonoscopy showed a 3-cm hemi-circumferential ulcer covered by blood clots and exudative materials with friable mucosa at rectum (Figure 1). Biopsy was done at the ulcer. Abdominal CT showed a 15-cm rim-enhancing cystic lesion with internal septation occupying right liver lobe. Capsule disruption at segment VIII/V anterior aspect of liver was noted (Figure 2). Percutaneous drainage was done and found markedly turbid gray pus 500 ml. Histopathologic findings revealed severe active proctitis with ulcer and few trophozoites ingested red blood cells on the surface, compatible with amoebic proctitis (Figure 3a). The pus aspirated from the abscess showed Charcot Leyden crystals (Figure 3b). Serum for E. histolytica antigen and PCR were both positive. The final diagnosis was amoebic liver abscess with proctitis. The patient was treated with metronidazole for 2 months, with a decreased size of abscess on follow-up CT. No recurrent bleeding occurred. DISCUSSION: Although synchronous colonic lesions in amoebic liver abscess are present in over 50% patient, diarrhea and bleeding are uncommon, without unclear reasons. Caecum is the most commonly affected site (70%). Left sided ulcers are seen in elderly and those presenting with diarrhea. Oral or intravenous metronidazole or tinidazole leads to rapid clinical improvement of invasive amoebic colitis and liver abscess. Large abscess (>7.7 cm) with abnormal liver tests were predictive of drainage intervention.