3b. A patient with fever, cough and right sided chest pain

 

Case history– A 40 year’s old man presents to you with history of high fever, cough and right sided chest pain for 3 days.

What are the diagnoses clinching in your mind?

Pneumonia

Liver abscess.

If a patient presents with the above features, you should be cautious as liver abscess may present with fever, cough (due to basal pneumonitis, which is dry) and right sided chest pain (may be due to liver abscess itself or diaphragmatic pleurisy).

If your diagnosis is pneumonia, follow 3.a. and if liver abscess 4.a.

 

 

4a. A patient with fever and right hypochondriac pain.

 

Case history– A 36 year’s gentle man presents with fever and right hypochondriac pain for 5 days.

What are the differential diagnoses in your mind?

Liver abscess

Viral hepatitis

Acute cholecystitis

What key questions would you ask?

  • Fever- high intermittent* fever with chills and rigors, subsides with sweating, comes several times in a day- liver abscess, acute cholecystitis.
  • Pain- constant pain in viral hepatitis

Stabbing pain which increase on deep inspiration- liver abscess

Initially colicky, later on constant pain on right hypochondrium- acute cholecystitis

  • Associated symptoms- anorexia, nausea and vomiting- viral hepatitis, vomiting also occurs in acute cholecystitis.

(NB. In this patient, hectic rise of temperature with chills and rigors, subsides with sweating and stabbing pain in right hypochondrium)

What will you examine?

General examination- Patient is ill looking, temperature is raised but jaundice is absent.

Abdomen examination- Liver is palpable and tender. Murphey’s sign** absent. Right lower intercostal space tender and swollen.

What is your provisional diagnosis?

Liver abscess

Investigations-

  • FBC- neutrophilic leucocytosis (WBC>11000 and neutrophil>70%)
  • USG of HBS- Investigation of choice- confirm the diagnosis.
  • X-ray chest PA view- normal, basal pneumonia or small effusion.

(NB. Now question is whether abscess is amoebic or pyogenic. In the era of antibiotic, pyogenic abscess is less common.)

Some differtiating points are

Trait Pyogenic Amoebic
History H/o cholangitis and septicemia

appendicitis

 H/o intestinal amoebiasis or amoebic dysentery(50%)
Organism E.coli

Various streptococci (strep.milleri)

Anaerobes

Bacteroids

 

 Entamoeba histolytica
Clinical features High fever with chills and rigors Mild to moderate fever
Age Old age/immune compromised Not so
Onset Acute Insidious
Investigation 50% multiple abscess

Neutophilic leucocytosis

Frank pus

 Single abscess 90%

Anchovy sauce pus
Treatment ampicllin gentamycin and metronidazole (AGM)

duration of Rx is more

 Metronidazole

Diloxanide furoate

Duration is less
Prognosis More fatal Less fatal

 

In amoebic liver abscess,

Alkaline phosphatase: increased in 70% cases

CFT, ICT (95% sensitive) in amoebic liver abscess.

Aspiration of pus under USG – anchovy sauce pus.

Confirmatory diagnosis- Amoebic liver abscess.

Treatment-

  • Metronidazole 800mg 8hourly for 5 days or 400mg 8 hourly for 10 days (Response occurs within 48 to 72 hours) followed by
  • Luminal amoebicide: Diloxanide furoate 500mg 8hrly for 10 days.
  • Aspiration if indicated