Occult Amebic Liver Abscess as Cause of Extensive Inferior Vena Cava and Hepatic Vein Thrombosis

Abstract

The most common extraintestinal complication of is amebic liver abscess (ALA). Hepatic vein and inferior vena cava (IVC) thrombosis are rare but well-documented complications of ALA, typically attributed to mechanical compression and inflammation associated with a large abscess. We present a case of a previously healthy 43-year-old Canadian man presenting with constitutional symptoms and right upper quadrant abdominal pain. He was found to have thrombophlebitis of the IVC, accessory right hepatic vein, and bilateral iliac veins. Extensive investigations for thrombophilia were negative. Magnetic resonance imaging of the liver demonstrated a 3.2-cm focal area of parenchymal abnormality that was reported as presumptive hepatocellular carcinoma, and a 1.9-cm lesion in the caudate lobe with diffusion restriction and peripheral rim enhancement. Despite multiple biopsy attempts, a histopathological diagnosis was not achieved. Abdominal pain and fever 4 months later prompted repeat ultrasound demonstrating a 10.4- × 12.0-cm rim-enhancing fluid attenuation lesion felt to represent a liver abscess. Thick dark "chocolate brown" drainage from the lesion and positive serology for confirmed the diagnosis of ALA acquired from a previous trip to Cuba. The patient was started on treatment with metronidazole and paromomycin and repeat abdominal ultrasound demonstrated resolution of the abscess. This case is the first to demonstrate extensive IVC thrombosis secondary to a relatively small occult ALA and emphasizes the thrombogenic potential of ALA. Amebic infection should be considered as a rare cause of IVC thrombosis in the correct clinical context.

A rare hepatic mass in an Italian resident

“…Because of abscess compression and mass effect on adjacent structures, extrinsic obstruction and subsequent reduced blood flow combined with the inflammatory environment due to the ongoing infection can lead to vein thrombosis, in agreement with Virchow's triad. Thrombosis of inferior and/or intrahepatic vena cava is a very rare complication of ALA only described in single case reports regarding patients born in endemic areas [10][11][12][13][14] or with well-determined source of infection [15]. Thrombosis of the portal vein and/or its ramifications is extremely rare but can be possible too [16,17].…”

Pulmonary Thromboembolism: A Rare Vascular Complication of Amebic Liver Abscess

“…Gupta et al and Khan and Ameen Rauf have described cases with right atrial thrombi secondary to ALA that required open surgical thrombectomy [ 9 , 10 ]. In the covert presentation of a case described by Martin et al, the patient had two small hepatic lesions (3.2 cm and 1.9 cm) along with thrombosis of the IVC, right accessory hepatic vein and bilateral iliac veins [ 11 ]. The lesions were initially felt to represent hepatocellular carcinoma but it could not be confirmed as multiple biopsies were non-conclusive.…”

Amebic liver abscess by Entamoeba histolytica

“…In rare cases, abscesses can rupture into the peritoneum, pericardium, or pleura, or into the hilum of the bile duct; they may also lead to septic emboli[ 2 ]. Thromboses of the hepatic vein and the inferior vena cava are uncommon ALA complications (though well documented) and are generally attributed to the inflammation and mechanical compression that accompany larger abscesses[ 60 ]. With ALAs, the combination of portal vein thrombosis and hepatic vein thrombosis is a common occurrence, frequently manifesting as segmental hypoperfusion in the portal venous phase and indicating ischemia[ 61 ].…”