Amoebic infection of the liver is not so common in children. Surprisingly, there is paucity of literature on amoebic liver abscess in Indian children. Udani et al¹ and Wagle² have reported ten cases an, one case respectively seen at autopsy. Mishra et al³ , Bamji et al⁴ and Das et al⁵ have reported a few case in Indian children. Most of the other cases reported in medical literature are from Latin America and Africa.

Age
McCarty et al⁶ observed that children under years of age have hepatic abscess more frequently than older children. Lasch and Brunean⁷ also found the highest incidence between the ages of 1-3 years. This is perhaps because at this age children tend to swallow things indiscriminately. Scragg⁸ has seen this condition at all ages. The youngest in his series of 53 African children was a seven weeks old baby. The youngest case reported by Manson-Bahr⁹ was a three month old Egyptian child.

Sex
Male predominance as in adults, has not been observed in children. The only exception to this statement is an unpublished series of 28 cases of Dalal¹⁰ where 21 children were males. It is worth noting that 21 cases in this series were in the age group of 3 to 12 years.

Diagnosis
The diagnosis of a liver abscess in children is often difficult. Therefore, awareness of the condition, especially in endemic areas, may aid in early detection.
The complaints are often non-specific, thus delaying the diagnosis. The most common symptoms are fever, abdominal discomfort or pain (more in the right upper quadrant of the abdomen). The child is very irritable and may present with vomiting.¹¹
A preceding history of dysentery may be elicited in these children. On examination, a-slight fullness in the right hypochondrium may be detected.¹²
The right lobe of the liver is involved more often than the left, the latter being involved only in cases of multiple abscesses.⁴ Mishra et al⁵ reported an infant with amoebic liver abscess of the left lobe, which responded to chloroquine. Scragg⁸ found that abscesses were more frequently multiple in children. Krishnamoorthy et al¹³ reported a case of amoebic pulmonary abscess in a seven year old boy. The invasion of the lungs was possibly secondary to hepatic involvement. Sputum yielded E. Histolytica on culture examination.

Investigations
Amoebic liver abscess in children may be diagnosed by the presence of leucocytosis, aspiration of typical pus from the liver, detection of trophozoites in stool or pus and positive amoebic serology. Liver scan must be carried out to determine the size, number and precise location of the abscess. A rectilinear scanner is not preferred for scanning the liver in small children as they are not usually cooperative. Gamma camera pictures are therefore often required.

Treatment
Specific anti-amoebic therapy with drainage of the abscess by percutaneous needle aspiration should be carried out. Because of the high mortality, a combination of drugs like metronidazole and emetine hydrochloride or dehydroemetine is recommended in children.¹⁴ Theoretically emetine is supposed to be avoided in children. However, Scragg and Powell, conducting a trial in 24 children found that emetine-induced cardiac toxicity was not a factor in causing death. The results showed that emetine was in fact well tolerated by children.¹⁵ In another series of 25 children, emetine was omitted and children were treated only with metronidazole in a dose of 50 mgm./kgm. per day orally for 5 days.¹⁶ The results equalled those of the combined therapy. Repeated aspirations were required in 19 cases. In 4 cases open surgical drainage was needed in addition to dehydroemetine. This drug in a dose of 2mg./kg. per day for ten days is preferred to emetine as it may be more effective and safer ever when administered in high doses.
Chloroquine is toxic to children if given in large doses.
Scragg and Proctor¹⁷ reported that tinidazole was highly effective in the treatment of amoebic liver abscess and cured 23 out of 25 children. But they found that the use of amoebicides did not diminish the value of aspiration. In fact, in selected cases, open drainage played a more effective role in children that in adults. This is because multiple abscesses are known to be inaccessible to needle aspiration frequently. This situation is less likely to arise in future, in institutions where radionuclide and ultrasonic scans are available.

Prognosis
This depends on the age of the patient.¹⁶ Sometimes regardless of therapy the mortality is higher in infants than in older children and adults. In Scragg's series, the mortality was 57%.⁸

References

1. Udani, P M, Ind. Pediat., 1970, 7, 286.
2. Wagle, M M, Ind. /. Child Health, 1958, 7, 107.
3. Mishra, ' D, and Mohante, K D, Ind. J. Pediat, 1969, 36, 481.
4. Bamji, M S. Dalal, Z P. et al, Post-Grad Med J., 1963, 9. 79
5. Das, B N. Mitra, S K, et al, Ind. Pediat., 1976, 13, 113.
6. McCarty, E, Wash, T. et al, Am. J. Dis. Child., 1973. 126. 67.
7. Lasch, E E, and Brunean, H. Ind. Pract.,20, 53
8. Scragg, I, Arch. Dis. Child., 1960, 35, 171.
9. Manson-Bahr, P. Manson's Tropical Dis Cassell & Co. Ltd., London, 1967.
10. Dalal Subhash, Personal communication.
11. O'Mara, B E, and McAfee, J G. J.Pediat., 77, 211.
12. Arnoit, W I I, Brit. Med. J. 1963, 1, 189.
13. Krishnamoorthv, P. Thomas, K, et al, Ind Pediat., 1967, 4 195.
14. Scragg, I N. and Powell, S J, Arch. Dis. Child., 1970, 45, 193.
15. Scragg, J N. and Powell, S J, Arch. Dis. Child., 1966, 41 549.
16. Scragg, J N. and Powell, S J, Arch. Dis. Child., 1970, 1973, 48, 911.
17. Scragg, J N. and Proctor, E M, Arch. Dis. Child., 1977, 52, 408.