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Asian Cardiovasc Thorac Ann 2000;8:387-388
© 2000 Asia Publishing EXchange Pte Ltd

CASE STUDY

Pleural Amebiasis: Isolated Organ Involvement

Rahmi Zeybek, MD, Egemen Tüzün, MD, Ihsan Iskesen, MD, Ömer Aksoy, MD

Department of Thoracic and Cardiovascular Surgery
Faculty of Medicine
Celal Bayar University
Manisa, Turkey
For reprint information contact: Rahmi Zeybek, MD Tel: 90 236 232 5889 Fax: 90 232 323 5240 email: kgenc{at}softhome.net Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Celal Bayar University, Manisa 45020, Turkey.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A rare case of pleural amebic abscess without invasion of another organ was encountered in a 23-year-old man. He was successfully treated surgically when conservative measures failed.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Amebiasis caused by Entamoeba histolytica is an endemic disease in tropical and subtropical countries and it remains one of the foremost causes of mortality among parasitic diseases.1,2 A case of pulmonary amebic abscess treated surgically when conservative measures failed, is described.


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 23-year-old man complained of an increasing dull ache on the right lower lateral thorax and fever without dyspnea, cough, or fatigue. His body temperature was 37.7°C, heart rate 92 beats•min–1, and blood pressure 120/70 mm Hg. He had no breath sounds on the right lower lateral zone of the thorax. The white blood cell count was 11,000/mm3 with polymorphonuclear leukocytes and a hematocrit of 30.9%. Repeated sputum smears were negative for acid-fast bacilli and a tuberculin skin test was negative. Stool examination was normal. A postero-anterior chest radiograph showed a slightly enlarged cardiac silhouette and a well-delineated oval homogenous opacity at the right lower lung field, which obscured the costodiaphragmatic sinus (Figure 1Go). Lateral chest radiography indicated that the opacity occupied the posterior portion of the right hemithorax. Abdominal ultrasound demonstrated no hepatic or other organ abnormality. Thoracoabdominal computed tomography revealed an oval cystic mass, 137 x 76 x 110 mm, located in the posterolateral portion of the right hemithorax without diaphragmatic and hepatic invasion. Marked pleural thickening was also observed (Figure 2Go). Casoni and Weinberg skin tests and serologic tests did not confirm hydatid disease but an indirect hemagglutination test for amebiasis was positive.



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  		Figure 1. Preoperative chest radiograph.

 


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  		Figure 2. Preoperative thoracic computed tomography scan showing a mass in the right lower lung lobe.

 
The patient was given metronidazole 500 mg orally 3 times daily for 10 days but the radiological picture and clinical status did not change. Therefore, under treatment with intravenous metronidazole 500 mg and ceftazidime 1 g per day, a right posterolateral thoracotomy was per-formed. A huge abscess and marked pleural thickening that prevented expansion of the right lower lobe were observed. The cavity was opened, 500 mL of chocolatebrown necrotic material was aspirated, and the lung was fully expanded following decortication (Figure 3Go). Symptoms resolved after the operation and the patient was discharged on the 7th postoperative day. Microscopic examination of the abscess wall and fluid did not reveal findings specific for amebiasis. At follow-up 18 months postoperatively, the patient remained asymptomatic.



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  		Figure 3. Postoperative thoracic computed tomography scan.

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
The intestinal protozoan parasite Entamoeba histolytica is the causative agent of human amebiasis and the disease is transmitted by ingestion of food and water containing cysts of the parasite.3 The cysts develop into the tropho-zoite stage in the intestine and cause colonic disease.1,3 In some cases, it is followed by dissemination to the extraintestinal organs, causing extraintestinal amebiasis.1,3 Although the liver is primarily involved, the lung is the second most commonly affected organ; the brain and spleen are rarely involved.1 Pleuropulmonary amebiasis is often seen as a complication of amebic liver abscess.2,4 Hematogenous spread to the lung with no other organ invasion occurs very rarely and only 2 cases were detected in 733 patients from 5 published series. The most common site of involvement is the right lower lobe of the lung. The patient often has a chronic illness with weight loss and fatigue; cough is the most common respiratory symptom but dyspnea and hemoptysis are also frequent. Pleural or hepatic involvement may cause lower thoracic or right upper quadrant pain.1 Laboratory findings such as leukocytosis, anemia, elevated erythrocyte sedimenta-tion rate, and positive serologic tests are nonspecific and may be completely normal.5 Chest radiography may show pleural effusion, elevated right diaphragm, right lower lobe consolidation, or infiltrates. Lung abscess usually occurs in the right lower lobe. Abdominal ultrasound and computed tomography may reveal hepatic amebiasis. Tuberculosis empyema, cancer, and pyogenic lung abscess might be considered in the differential diagnosis.1

Conservative treatment with metronidazole or emetine must be tried initially.6 If this fails, surgical therapy such as intercostal drainage, decortication, or lobectomy must be considered in a case of severe pleural thickening or lung destruction.1,6 The clinical picture in this patient was not definitive for pleuropulmonary amebiasis but positive serologic tests established the diagnosis. Surgery was performed when conservative treatment failed. Although tissue diagnosis could not be made, the chocolate-brown abscess fluid was thought to be highly characteristic of amebic abscess. We recommend that in endemic areas, pleuropulmonary amebiasis without invasion of another organ be kept in mind. Surgical treatment is indicated after failure of conservative measures.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Kennedy D, Sharma OP. Hemoptysis in a 49-year-old man. An unusual presentation of a sporadic disease. Chest 1990;98:1275–8.[Abstract/Free Full Text]

  2. Ragheb MI, Ramadan AA, Khalil Mah. Intrathoracic presentation of amebic liver abscess. Ann Thorac Surg 1976;22:483–9.[Abstract]

  3. Li E, Stanley SL Jr. Protozoa amebiasis. Gastroenterol Clin North Am 1996;25:471–92.[Medline]

  4. Lycke KD, Jensen WA. Pleuropulmonary amebiasis. Semin Respir Infect 1997;12:106–12.[Medline]

  5. Reed SL. Amebiasis: an update. Clin Infect Dis 1992; 14:385–93.[Medline]

  6. Cameron EWJ. The treatment of pleuropulmonary amebiasis with metronidazole. Chest 1978;73:647–50.[Abstract/Free Full Text]





This Article
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