Dyspnea and Dysentery: A Case Report of Pleuropulmonary Amebiasis

Merica Shrestha, MD; Anita Shah, DO; Christopher Lettieri, MD

Disclosures

South Med J. 2010;103(2):165-168. 

In This Article

Case Report

A 52-year-old previously healthy man presented with a 10-day history of fevers, right upper quadrant abdominal pain and bloody diarrhea. He reported intermittent fevers and night sweats, but denied vomiting or hematemesis. He had multiple episodes of large volume bloody diarrhea. His systemic review was otherwise normal. The patient was an active duty United States Army soldier who had been stationed in Liberia for three months. He was otherwise healthy and had no prior history of parasitic infections.

He initially presented to a local Liberian hospital and was found to be febrile, diaphoretic, hypotensive and tachycardic. Breath sounds were normal bilaterally and cardiac exam did not reveal any murmurs. Diffuse abdominal tenderness was noted; however, there was no guarding or rebound tenderness. Laboratory analysis revealed a leukocytosis with a white blood cell count of 32,600/mcL (89% segmented neutrophils, 5.5% lymphocytes, 0.6% eosinophils, 4.6% monocytes) and a hematocrit of 25.8 g/dL. An acute abdominal series was normal. The patient was admitted to the hospital and underwent a colonoscopy which revealed multiple cecal ulcerations and edematous, friable and necrotic mucosa of the cecum and proximal ascending colon. On the second hospital day, the patient suddenly developed dyspnea, a productive cough with green-gray sputum and right-sided pleuritic chest pain. Chest roentgenogram revealed an elevated right hemidiaphragm and pleural effusion (Fig. 1). Computed tomography (CT) scan of the chest and abdomen revealed multiple hepatic abscesses, the largest measuring 7 cm × 7 cm, and was associated with diaphragmatic erosion (Fig. 2). The CT also showed a large right-sided loculated pleural effusion causing lateral displacement of the mediastinum (Fig. 3). Empiric metronidazole was initiated, and the patient was evacuated to the United States for further evaluation.

Figure 1.

Chest radiograph (PA/lateral) showing a right elevated hemidiaphragm and pleural effusion.

Figure 2.

CT of the abdomen showing 3 liver abscesses. The largest, 7 cm × 7 cm, eroded through the diaphragm causing a 2.75 cm defect.

Figure 3.

CT chest showing a large, loculated right pleural effusion crossing the midline, anterior to the vertebral bodies causing lateral displacement of the mediastinum and a moderate-sized pericardial effusion.

Diagnostic thoracentesis revealed opaque, brown fluid with a white blood cell (WBC) count of 113,400 cu/mm, red blood cells (RBC) of 45,360 cu/mm, pH 6.4, lactate dehydrogenase (LDH) 65,659 U/L, total protein 2.6 g/dL and glucose 41 mg/dL. Serum malaria and serum/fecal ova and parasite testing was negative. Enzyme immunoassay testing confirmed a positive Entamoeba histolytica pleural fluid antigen and serum IgG antibody. The patient was therefore diagnosed with pleuropulmonary amebiasis. Given the large loculated pleural effusion and large diaphragmatic defect, the patient underwent video-assisted thoracoscopic surgery (VATS) with decortication and chest tube drainage as definitive treatment for the empyema. Surgical repair of the diaphragmatic defect was not performed due to inadequate healing from local infection. He was treated with a full course of metronidazole and paramomycin resulting in clinical and radiologic improvement. A 6 week follow-up CT scan showed reduction in the size of the liver abscesses, resolution of the pericardial effusion and near resolution of the parenchymal involvement (Fig. 4).

Figure 4.

CT chest and abdomen at 6 weeks post-therapy showing reduced size of liver abscesses and resolution of pleural effusion.

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