Microbiology Case Study: A 52 Year Old with a Liver Abscess

Clinical history

A 52 year old patient with a history of recent travel to India presented to interventional radiology from an outside hospital for aspiration of a liver abscess, and was subsequently returned to the outside hospital. The patient had spent 2 months in India before returning to the US, and about 1 month later developed right upper quadrant pain. Abdominal CT showed 2 cystic masses measuring 2-4cm. Aspiration of the cysts yielded 0.5mL of bloody fluid, which was sent for bacterial culture and smear. Infectious disease prescribed antimicrobial treatment consisted of ceftriaxone and metronidazole, followed by paromomycin and levofloxacin.

Laboratory findings

A gram smear of the patient’s liver mass aspirate showed few neutrophils and no bacteria. Culture of the aspirate showed no growth at 5 days. Multiple sets of blood cultures collected at the outside hospital all showed no growth at 5 days.

Image 1. Entamoeba coli trophozoite seen in the patient’s stool ova and parasite exam, demonstrating an eccentric karyosome and coarse, irregular peripheral chromatin.

A single ova and parasite exam of the patient’s stool was sent and showed few Entamoeba coli trophozoites. A sample of the patient’s blood was sent to the Mayo reference lab for serum Entamoeba histolytica antibody testing, which came back positive. Stool was sent for Entamoeba histolytica antigen testing which was negative.

Discussion

Entamoeba coli is a non-pathogenic protozoan that can exist as a commensal organism in the human gastrointestinal tract. This organism has not been established to have any disease causing effect per se, but its presence may indicate exposure to water sources that could contain parasitic organisms. (3)

Entamoeba histolytica, by contrast, is a parasitic protozoal pathogen. Most infections are asymptomatic, but they can manifest as amebic dysentery or extraintestinal disease. The most common extraintestinal manifestation is amebic liver abscesses.1

Intestinal amebiasis occurs via ingestion of amebic cysts, typically through contaminated food or water, but also through other forms of fecal-oral contact. Infections are seen most commonly in areas with poor sanitation, but can be found in developed countries in patients who have migrated from or traveled to endemic areas.2

Once the amebic cysts pass into the small intestine, they form trophozoites, which are able to penetrate the mucous barrier of the gut and destroy intestinal epithelial cells. This leads to blood and mucus in the stool. (2) Once the amebae penetrate the gut wall, they are able to reach the blood and ascend through the portal system to the liver and form amebic liver abscesses.3

Clinical presentation of these abscesses typically includes right upper quadrant pain and fever in a patient with a history of travel to an endemic area. Serologic testing is used for confirmation if clinical presentation and imaging are suggestive, but this cannot distinguish between current infection and prior exposure, and up to 35 percent of uninfected inhabitants of endemic areas show positive serology.3 Stool microscopy may be the initial, and indeed only test available in some areas, but cannot differentiate E. histolytica from non-pathogenic E. dispar and E. moshkovskii strains.2

Image 2. E. histolytica trophozoite with ingested red blood cell, visible as a dark inclusion, as well as demonstrating a central karysome and fine, uniformly distributed chromatin. (CDC: https://www.cdc.gov/dpdx/amebiasis/index.html) Erythrophagocytosis is suggestive of E. histolytica.

Empiric treatment in the setting of consistent epidemiology, clinical picture, and radiology consists of metronidazole or tinidazole for tissue clearance followed by paromomycin, diiodohydroxyquin, or diloxanide furoate for intraluminal clearance.

Infectious diseases was taking care of this patient and decided her clinical syndrome is probably extraintestinal Entamoeba histolytica amoebiasis based on the results of the CT findings and the antibody in the right clinical setting.  Although her stool ova and parasite only showed Entamoeba coli, she clearly has been exposed to contaminated food or water.  In addition, the Entamoeba histolytica stool antigen was negative, but this can be an insensitive test.

References

  1. Leder, Karin, and Peter F. Weller. “Extraintestinal Entamoeba histolytica amebiasis.” UpToDate, Wolters Kluwer, 27 Jan. 2020, http://www.uptodate.com/contents/extraintestinal-entamoeba-histolytica-amebiasis?search=entamoeba%20histolyticatreatment&topicRef=5727&source=see_link. Accessed 4 Feb. 2020.  
  2. Leder, Karin, and Peter F. Weller. “Intestinal Entamoeba histolytica amebiasis.” UpToDate, Wolters Kluwer, 27 Jan. 2020, http://www.uptodate.com/contents/intestinal-entamoeba-histolytica-amebiasis?search=entamoeba%20histolyticatreatment&source=search_result&selectedTitle=1~46&usage_type=default&display_rank. Accessed 4 Feb. 2020.
  3. Weller, Peter F. “Nonpathogenic enteric protozoa.” UpToDate, Wolters Kluwer, 25 July 2019, http://www.uptodate.com/contents/nonpathogenic-enteric-protozoa?search=entamoeba%20coli%20treatment&source=search_result&selectedTitle=1~6&usage_type=default&display_rank=1. Accessed 4 Feb. 2020.

-Tom Koster, DO is a 1st year Anatomic and Clinical Pathology Resident at the University of Vermont Medical Center.

-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

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