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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 99-101
Residual amoebic liver abscess in a prospective renal transplant recipient


Department of Urology, Christian Medical College and Hospital, Vellore, India

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Date of Web Publication3-Jan-2012
 

   Abstract 

Amoebic liver abscess (ALA) is by far the most common extraintestinal manifestation of invasive amoebiasis. The vast majority of these resolve with treatment; however, a small percentage of the treated ALAs are known to persist asymptomatically. Herein, we present a prospective renal allograft recipient with a residual liver abscess who had a successful renal transplant after treatment. In our opinion, persistence of a radiological finding of residual abscess in the absence of clinical disease does not appear to be a contraindication to renal transplantation.

How to cite this article:
Choudhrie AV, Kumar S, Gopalakrishnan G. Residual amoebic liver abscess in a prospective renal transplant recipient. Saudi J Kidney Dis Transpl 2012;23:99-101

How to cite this URL:
Choudhrie AV, Kumar S, Gopalakrishnan G. Residual amoebic liver abscess in a prospective renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Jul 22];23:99-101. Available from: http://www.sjkdt.org/text.asp?2012/23/1/99/91310

   Introduction Top


Amoebic liver abscess (ALA) is by far the most common extraintestinal manifestation of invasive amoebiasis. The main presenting symptoms are fever and abdominal pain. Diagnosis is based on imaging and serological tests. These are most commonly solitary and located in the right lobe of the liver. Ultrasonography (USG) is a commonly used screening test, with a sensitivity of 85-95%. It allows diagnostic or therapeutic drainage at the time of performance and is useful in the follow-up of these patients. [1] Seven percent of treated ALAs are known to persist asymptomatically. [2] We present a prospective renal transplant recipient with a residual liver abscess.


   Case Report Top


A 29-year-old male with chronic kidney disease stage V on maintenance hemodialysis, during pre-transplant evaluation, was detected to have a residual liver abscess. Five years ago, he had had right upper abdominal pain associated with high-grade fever. He was detected to have a hepatic abscess for which he underwent aspiration followed by a course of antimicrobials; the details of treatment are not known. Ultrasound scan of the abdomen revealed a 45.5 mm × 46.9 mm iso-echoic area with a hypoechoic area [Figure 1] in segment 7 of the liver with a normal-sized liver and no intrahepatic biliary dilatation.
Figure 1: Ultrasound image of the residual liver abscess.

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Contrast computed tomography (CT) revealed a thick-walled fluid attenuation lesion near the subdiaphragmatic location measuring measuring 47 mm × 43 mm [Figure 2]. Aspiration yielded thick pus, but there was no growth on fungal or pyogenic culture and there were no trophozoites or acid fast bacilli on smear.
Figure 2: CT scan image of the residual liver abscess.

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Infectious disease and general surgery consults were sought, and it was considered most likely to be a residual ALA, as such lesions are known to persist asymptomatically. He underwent therapeutic pigtail drainage of the liver abscess and approximately 60 mL of pus was drained. He received three weeks of metronidazole and diloxanide furoate. Follow-up ultrasound showed the lesion to persist [Figure 3].
Figure 3: Ultrasound image of the residual liver abscess after aspiration.

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He underwent live related renal transplantation, his father being the donor. Immunosuppression used was tacrolimus, mycophenolate mofetil, prednisolone and interleukin-2 receptor blockade with basiliximab. He received empirical antibiotics consisting of amoxycillinclavunate, ceftazidime and metronidazole for five days. He was discharged on the sixth post-operative day with a nadir creatinine of 1.4 mg/dL. Renal functions were stable at 12 months and ultrasound revealed the lesion to be static.


   Discussion Top


To the best of our knowledge, there are no reports of ALA in a renal allograft recipient or in a prospective recipient. Anecdotal reports are available in the literature regarding acanthamoebic, [3] tuberculous [4] and hemophilus parainfluenzae [5] hepatic abscess in renal transplant recipients. In our patient, the abscess had persisted asymptomatically for more than five years pre-transplant. He received treatment to eliminate this source of infection that could flare up following immunosuppression. Because he had been asymptomatic for the past five years, with negative microbiological cultures, he was considered for renal transplantation. Although the follow-up is short, this patient has not had fever, abdominal pain or jaundice to suggest flare up of the residual abscess. The residual cavity has remained static on follow-up.

It is known that residual or persistent forms of liver abscess do exist and occur independent of treatment modality (medical or medical + drainage). Several authors have noted an incidence of 5-28% of residual abscess. [6],[7] These have been noted to persist for as many as 36 months and, in one case, for more than 13 years. [2] Ultrasound scanning has been used in the follow-up of these lesions in these series. [2],[6],[7]

Typically, the lesions were hypoechoic or isoechoic, resembling liver parenchyma with a hyperechoic wall. Occasionally, lesions may show acoustic shadows suggesting some degree of calcifications. These lesions have been noted to be asymptomatic and do not require any further treatment. The mechanism(s) responsible for persistence of these lesions in only a small percentage of ALA patients remain to be elucidated. [2]

Sources of infection need to be eliminated prior to instituting immunosuppression. This, however, may not be possible, and persistence of a radiological finding in the absence of clinical disease does not appear to be a contraindication to renal transplantation, as seen in this case. Although no active intervention has been recommended in asymptomatic patients, [2],[6] residual ALA in a renal transplant recipient presents a dilemma in the management due to paucity of data in the literature. Recipients must completely understand the risks and need for regular follow-up once graft function has stabilized.

 
   References Top

1.T Townsend CM, Beuchamp RD, Evers BM, Meyers WC. The liver-Pyogenic and amoebic liver abscess. In: Sabiston Textbook of Surgery. 17th ed. Sabiston DC Jr, Lyerly HK, eds. W.B. Saunders Company. Philadelphia, Pennsylvania. 2004:1513-67.  Back to cited text no. 1
    
2.Blessmann J, Khoa ND, Van An L, Tannich E. Ultrasound patterns and frequency of focal liver lesions after successful treatment of amoebic liver abscess. Trop Med Int Health 2006;11(4):504-8  Back to cited text no. 2
    
3.Mutreja D, Jalpota Y, Madan R, Tewari V. Disseminated acanthamoeba infection in a renal transplant recipient: A case report. Indian J Pathol Microbiol 2007;50(2):346-8.  Back to cited text no. 3
    
4.Caliskan Y, Demirturk M, Cagatay AA, et al. Isolated hepatic tuberculous abscess in a renal transplant recipient. Transplant Proc 2006;38 (5):1341-3.  Back to cited text no. 4
    
5.Desir G, Helman D, Herlich M, Turka L, Bia MJ. Haemophilus parainfluenzae liver abscess in a recipient of a renal transplant who had polycystic disease. JAMA 1986;255(14):1878.  Back to cited text no. 5
    
6.Gbesso RD, Kéita AK. Ultrasonography of amoebic liver abscesses. Proposal of a new classification. J Radiol 1997;78(8):569-76.  Back to cited text no. 6
    
7.Ralls PW, Quinn MF, Boswell WD, Colletti PM, Radin DR, Halls J. Patterns of resolution in successfully treated hepatic amoebic abscess: sonographic evaluation. Radiology 1983;149: 541-3.  Back to cited text no. 7
    

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Correspondence Address:
Ashish V Choudhrie
Senior Registrar (PG), Christian Medical College and Hospital, Vellore - 632 004
India
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PMID: 22237227

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  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
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