International Journal of Current Research and Review
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IJCRR - 9(18), September, 2017

Pages: 12-13

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Amoebic Peritonitis Associated with Cirrhosis of Liver: A Case Report

Author: Kavita Ashish Bhilkar, Chhaya Chande, Amandeep Singh, Abhiroop Verma, Abhay Chowdhary

Category: Healthcare

Abstract:Introduction: Amoebic peritonitis is due to the rupture of amoebic liver abscess or perforation of amoebic colitis. Amoebic peritonitis is associated with very high mortality. Methodology: A case of amoebic peritonitis is reported in a young adult female with live cirrhosis. The diagnosis of amoebic peritonitis was established by the demonstration of trophozoites in the ascitic fluid and significant titres in indirect haemagglutination test.
Result: Cytopathological examination of peritoneal fluid showed presence of large number of trophozoites of E. histolytica. Anti E. histolytica serum antibodies by indirect haemagglutination(IHA) were present in titres 1:320.
Conclusion: A high index of suspicion in any case of colitis along with serological testing is indicated for the early diagnosis and timely management.

Keywords: Amoebic perironitis, Perforative peritonitis, E. Histolytica.

Full Text:

Introduction

Amoebiasis is a parasitic infection caused by protozoan Enatamoeba histolytica. Infection by E histolytica is endemic in Indian subcontinent with as high as 67% prevalence rate.[1] Invasive amoebiasis is associated with significant morbidity and mortality in areas endemic for E. histoltytica. [2] Colonic perforation, liver abscess, pleural and pericardial effusion, enteric fistulae and amoeboma formation are some of the complications of invasive amoebiasis. [3] Amoebic peritonitis is most often due to the rupture of amoebic liver abscess. Nearly 22% cases of Amoebic liver abscess can rupture to give peritonitis.[4,5] The colonic perforation cases are extremely rare.[6] Here we report a fatal case of amoebic peritonitis affecting young adult female patient.

Case Report

A 38 year old female was admitted with history of distension of abdomen since two months and pedal oedema since 10 days. She had diarrhoea and abdominal pain since three months. There was no history of fever, haetemesis, malena or convulsions. No history suggestive of tuberculosis, Diabetes mellitus, hypertension and receiving blood transfusion in past. On physical examination she had icterus and abdominal distension with tenderness. There was no lymphadenopathy. On examination, RS, CVS and CNS were normal. Laboratory investigations showed that the total leucocytes count was 13300 with polymorphs 70%, Lymphocytes 25%, Eosinophils and monocytes 3% and 2% respectively. Liver function tests showed significant rise in total bilirubin and raised SGOT (78IU/mL) and SGPT (148 IU/mL). Serum creatinine was 3mg/dl and blood urea was 68mg%. HIV, HBsAg, HCV and HAV serology was negative. The alpha fetoproteins were raised (87.75IU/mL) where as beta chorionic gonadotrophins were within normal range. USG abdomen revealed splenomegaly, nodular liver with irregular surface and liver parenchymal disease consistent with cirrhosis of liver and gross ascites. CT scan of abdomen was suggestive of cirrhosis of liver with changes of portal hypertension. The aspirated ascitic fluid was dark yellow with alkaline pH and sugar 102%. Cytopathological examination of peritoneal fluid showed presence of RBCs, WBCs and large number of trophozoites of E. histolytica. Anti E. histolytica serum antibodies by indirect haemagglutination(IHA) were present in titres 1:320.

The patient was treated with parenteral Metronidazole and a third generation cephalosporin, Ceftriaxone. However, the patient did not show any response to the treatment, developed acute renal failure and died on the 6th day of admission. An autopsy was performed which confirmed the diagnosis of cirrhosis liver; however colonic invasion was not substantiated on autopsy.

Discussion

Amoebic peritonitis could be either due to rupture of amoebic liver abscess into peritoneum or due to perforation of invasive amoebic colitis.[5] Ruptured Amoebic liver abscess is the most common cause of amoebic peritonitis accounting for 22 to 32% cases.[4,5]

Perforation with peritonitis is uncommon and reported in 3 to 5 % autopsies on patients dying of amoebisis.[6] Incidence of perforation in amoebic colitis is around 2% with a high mortality rate regardless of the treatment.[7] Amoebiasis is the most common cause of colonic perforation besides TB and malignancy.[8]

The present case was diagnosed as Amoebic peritonitis on the basis of presence of trophozoite forms of E. histolytica in ascitic fluid and positive IHA test. However, there was no clinical evidence of amoebic liver abscess or bowel perforation in though the patient had symptoms suggestive of amoebic colitis. Fever, chronic diarrhoea and abdominal pain are the main presenting symptoms in invasive amoebiasis. As Ultrasonography revealed presence of findings consistent with cirrhosis, the ascites was attributed to the cirrhotic changes in liver parenchyma and altered liver function. In the absence of any indication of liver abscess and presence of trophozoites in the ascetic fluid along with positive IHA test, the diagnosis of amoebic peritonitis secondary to bowel leak was entertained. The amoebic peritonitis may be caused by either frank perforation or through a slow leak through diseased bowel.[9,2,3] There are three forms of perforation, an extraperitoneal sealed perforation, a perforation of amoebic ulcer or amoeboma and a perforation in the presence of acute dysentery. Extra-intestinal disease via haematogenous spread to the liver, lung, brain and rarely other organs is reported in invasive amoebisis.

High mortality is reported in amoebic peritonitis secondary to bowel perforation as compared to rupture of amoebic liver abscess.

In the present case, the diagnosis of amoebic peritonitis was established by the demonstration of trophozoites in the ascitic fluid and significant titres in indirect haemagglutination test. Serologic testing for amoebisis is highly specific, the IHA is considered as the most specific test.[10]

Conclusion

Considering the high endemicity of the disease and high fatality rate of amoebic colitis[2], a high index of suspicion in any case of colitis along with serological testing is indicated for the early diagnosis and timely management.

References:

  1. Mahajan RC, Sehgal R,Ganguly NK. Recent developments in amoebiasis research. Ind Rev Life Sci. 1991;11:139-167.
  2. Jain BK, Garg PK, Kumar A, Mishra K, Mohanty D, Agrawal V. Colonic perforation with peritonitis in amoebiasis: A tropical disease with high mortality. Trop Gastroenterol. 2013;34(2):83-86.
  3. Adams EB and Macleod IN. Invasive amoebiasis I. Amoebic dysentery and its complications. Medicine (Baltimore) 1977; 56:315-323.
  4. Mukhopadhyay M, Saha AK, Sarkar A, Mukherjee S. Amoebic liver abcess: presentation and complications. Indian J Surg 2010;72: 37-41.
  5. Monga NK, Sood S, Kaushik SP, Sachdeva HS, Sood KC, Datta DV. Amoebic peritonitis. Am J Gastroenterol. 1976;66(4):366-373.
  6. Archampong EQ and Clark CG. Surgical problems in Amoebiasis. Ann. Roy. Coll. Surg. Engl. 1973;52:36-48.
  7. Eggleston FC, Verghese M, Handa AK. Intraperitoneal rupture of amoebic liver abcess. Br J Surg. 1989;76:202-203.
  8. Singla K, Mahajan G, Agarwal S, Sharma S. Role of histopathological examination in nontraumatic perforation of colon. Trop Gastroenterol. 2012;33(4):265-269.
  9. Essenhigh DM and Carter RL. Massive necrosis of the colon due to amoebiasis. Gut 1966;7: 444-447.
  10. Hung CC, Chen PJ, Hsiegh SM, Wong JM, Fang CT, Chang SC et al. Invasive amoebiasis: an emerging parasitic disease in patients infected with HIV in an area endemic for amoebic infection. AIDS 1999; 13 (17):2421-2428.

 

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A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
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A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
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A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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