Amoebic Liver Abscess Complicated By Hepatocaval-Right Atrial Thrombosis And Transdiaphragmatic Pleuropulmonary Rupture: A Case Report

Abstract

Background: Amoebic liver abscess (ALA) is the most common extraintestinal manifestation of Entamoeba histolytica infection. Thoracic rupture is a recognized complication, whereas extension of hepatic venous thrombosis through the inferior vena cava (IVC) into the right atrium is exceptionally rare and potentially life-threatening. We report an unusual case in which both complications occurred simultaneously.

Case presentation: An 18-year-old man presented with high-grade fever, chills, abdominal distension, and abdominal tenderness. Leukocytosis was present. Ultrasonography showed a hepatic abscess with associated IVC thrombosis, prompting contrast-enhanced CT. CT demonstrated a large, thick-walled, peripherally enhancing abscess measuring approximately 6.8 cm and involving segments I, IVa, VII, and VIII, with hepatomegaly. Thrombus involved the middle and right hepatic veins and extended contiguously through the intrahepatic IVC to the right atrium. Transthoracic echocardiography confirmed a freely mobile right atrial thrombus. Superiorly, the abscess breached the right hemidiaphragm through an approximately 27-mm defect and extended directly into the adjacent pleural/subpleural compartment and posterior right lower lobe, where focal consolidation with surrounding ground-glass opacity was present. Indirect hemagglutination assay for E. histolytica was positive at a titre of 1:250. The patient was resuscitated and treated with intravenous metronidazole and low-molecular-weight heparin. Because of the freely mobile intracardiac thrombus and the associated embolic risk, open surgical thrombectomy was performed together with operative drainage of the liver abscess. Characteristic anchovy-sauce material was obtained. The patient recovered uneventfully and was discharged on postoperative day 10. At 1 month, follow-up ultrasonography showed no significant residual hepatic or vascular abnormality.

Conclusion: ALA may rarely produce simultaneous hepatocaval-intracardiac thrombosis and transdiaphragmatic pleuropulmonary rupture. CT is essential for defining the full anatomic extent of disease, whereas echocardiography provides critical information about intracardiac thrombus mobility. A freely mobile right atrial thrombus should prompt urgent multidisciplinary assessment because surgical thrombectomy may be required in selected patients.