Persistent fever and right hypochondrium pain.

Roland T, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221254 Description A 39-year-old patient was admitted to our hospital for 10 days fever (up to 40°C) with pain in the right hypochondrium. Abdominal echography performed at the onset of symptoms was normal. Blood tests showed C-reactive protein 311 mg/L, leucocytes count 24x10 /L (neutrophils count at 19, 29x10/L), bilirubin 1.1 mg/dL, lactate dehydrogenase (LDH) 254 U/L, aspartate aminotransferase (ASAT) 67 U/L, alanin aminotransferase (ALAT) 66 U/L, gammaGlutamyltransferase (gGT) 79 U/L and alkaline phosphatase 221 U/L. Chest X-ray showed an infiltrate in the right lung base. A diagnosis of pneumonia was made and treatment with cefuroxime started. Since fever and right hypochondrium pain persisted despite antibiotherapy for 5 days, abdominal CT scan was performed, which demonstrated a large hepatic mass of 10×7 cm (figure 1). Percutaneous drainage revealed a thick and brown liquid; ‘chocolate-like’ (figure 2). Complementary information came from anamnesis: the patient usually lives in Cambodia and he has had dysentery 3 months ago. Clinical and biological evolution was well under metronidazole 500 mg three times a day for 10 days. Entamoeba serology (antibody detection with indirect fluorescent antibody technique) came back positive (1/800). A diagnosis of amoebic abscess was retained and the patient completely recovered at the end of the treatment (paromomycin for 7 days after metronidazole). Amoebic liver abscess is caused by Entamoeba histolytica. Antibiotic such as metronidazole is the usual treatment for liver abscess. Paromomycin has also to be taken to prevent the recurrence. In rare cases, the abscess may need to be drained to relieve some of the abdominal pain (abscesses greater than 5 cm).