Development of amoebic liver abscess in early pregnancy years after initial amoebic exposure: a case report

Abstract

Background: Infection with Entamoeba histolytica and associated complications are relatively rare in developed countries. The overall low prevalence in the Western world as well as the possibly prolonged latency period between infection with the causing pathogen and onset of clinical symptoms may delay diagnosis of and adequate treatment for amoebiasis. Amoebic liver abscess (ALA) is the most common extraintestinal manifestation of invasive amoebiasis. Pregnancy has been described as a risk factor for development of invasive amoebiasis and management of these patients is especially complex.

Case presentation: A 30-year-old Caucasian woman in early pregnancy presented to our emergency department with abdominal pain alongside elevated inflammatory markers and liver function tests. Travel history revealed multiple journeys to tropic and subtropic regions during the past decade and a prolonged episode of intermittently bloody diarrhea during a five month stay in Indonesia seven years prior to admission. Sonographic and magnetic resonance imaging revealed a 5 × 4 cm hepatic abscess. After ultrasound-guided transcutaneous liver drainage, both abscess fluids and blood cultures showed neither bacterial growth nor microscopic signs of parasitic disease. Serological testing confirmed an infection with Entamoeba histolytica, which was treated with metronidazole, followed by eradication therapy with paromomycin. Subsequent clinical, laboratory and imaging follow-up exams showed regression of the ALA. In addition, the pregnancy completed without complications and a healthy baby boy was born 7 months after termination of treatment.

Conclusions: This case of invasive amoebiasis in early pregnancy outside of endemic regions and several years after exposure demonstrates the importance of broad differential diagnostics in the context of liver abscesses. The complex interdisciplinary decisions regarding the choice of imaging techniques as well as interventional and antibiotic therapy in the context of pregnancy are discussed. Furthermore, we present possible explanations for pregnancy as a risk factor for an invasive course of amoebiasis.

Keywords: Amoebic liver abscess; Case report; Embryotoxicity; Entamoeba histolytica; Paromomycin; Pregnancy.

Fig. 1

Timecourse of the patient’s travel history as well as the pre-, intra- and post-hospital course of treatment

Fig. 2

a 2D abdominal ultrasound performed on the day of presentation shows a hypoechogenic, inhomogenous and approximately 4 × 5 cm large lesion in hepatic segment V. b Contrast-enhanced ultrasound of the liver reveals peripheral hypervascularization of the lesion in segment V without central uptake of contrast, a finding consistent with liver abscess

Fig. 3

a Coronary MRI image of the liver without contrast reveals a T1-hypointense hepatic lesion, adjacent to the gall blader (indicated with *). b Axial MRI sequences showing diffusion restriction to the center of the lesion (* = gall bladder). c 2D sonography after successful transhepatic puncture and drainage. The green dots depict the direction of puncture, the hyperechogenic reflexes within the lesion are caused by the drainage