A 22-year-old male presented to the emergency department with high-grade fever and chills for 3 months' duration. Fever was associated with cough and expectoration for the last 11/2 month with occasional brownish-red sputum for 1 month. He had headache and progressive drowsiness for the last 2 days. There was no history of vomiting, photophobia, seizures, or loss of consciousness. He did not have any drug addictions or high-risk sexual behavior.
At presentation, he was conscious but disoriented with a Glasgow Coma Score of 12/15. He was febrile (102 F ) and had tachycardia with normal blood pressure. Systemic examination revealed mild pallor and reduced breath sounds at the right infrascapular region, and the liver was tender and enlarged till 15 cm below the right costal margin. Signs of meningeal irritation were present without any focal neurological deficit. Investigations revealed severe anemia (hemoglobin - 6.2 g/dL), neutrophilic leukocytosis (total leukocyte count [TLC] - 20,900/mm3 with 80% neutrophils), hypoalbuminemia (serum albumin 2.0 g/dL), and raised alkaline phosphatase (435 IU/L). Blood and urine cultures revealed no growth. His chest X-ray showed an elevated right hemidiaphragm with mild pleural effusion. Abdominal ultrasound and contrast-enhanced computed tomography (CECT) scan of the thorax and abdomen revealed a single large abscess of approximately 750 cc volume in the right lobe of the liver with evidence of rupture into the right subdiaphragmatic space [Figure 1]. The patient was started on broad-spectrum intravenous antibiotics including metronidazole since the day of admission. Subsequently, a pigtail catheter was inserted into the liver abscess which drained around 1.2 l of anchovy sauce-like pus over 2 days. Drained liver abscess pus on evaluation revealed TLC-full field (N - 70% and L - 30%), sterile for bacterial and fungal cultures and negative for amebic trophozoite and malignant cells on microscopic examination as well as negative for Mycobacterium tuberculosis-Gene-Xpert.
As patient orientation was not improved, magnetic resonance imaging (MRI) scan of the brain was done about 6 days later of initiation of antibiotics, which showed a large, ring-enhancing, intracranial, space-occupying lesion involving the bilateral frontal lobes with significant perilesional edema [Figure 2]. Keeping the possibility of primary brain tumor versus metastatic abscess, neurosurgical consultation was sought, and the patient was considered for drainage of abscess. Intraoperative findings revealed rusty, brown-colored, organized abscess extending into the third ventricle with bilateral anterior cerebral artery thrombosis. Microscopy of the pus from the liver and brain did not reveal any amebic trophozoite, Gram stain was negative, and bacterial cultures were sterile.
The patient responded well to the treatment with parenteral metronidazole and antibiotics along with drainage of liver and brain abscesses. He became afebrile, and leukocytosis resolved after 72 h of starting treatment. His sensorium was also improved, but he had persistent urinary incontinence and disorientation, which improved gradually over 3 weeks. His enzyme-linked immunosorbent assay test for Entamoeba histolytica immunoglobulin G was done with RIDASCREEN kit from r-Biopharm (Darmstadt, Germany), which was reported positive, suggesting amebic etiology of liver and brain abscesses. After 2 weeks of parenteral therapy, he was continued with oral metronidazole for another 2 weeks. Subsequently, MRI scan of the brain and CECT of the abdomen were repeated, which showed almost complete resolution of brain abscess and minimally organized residual abscess in the liver [Figures 3 and 4]. He was discharged after 5 weeks of hospital stay, and after 6 months of follow-up, he did not have any residual neurological symptoms.