![[Amoebic Liver Abscess]](images/nav/p_amoebic.gif){kind=small} ![[Dr. O.P. Kapoor]](images/nav/p_dropk.gif){kind=small} |
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TREATMENT OF PLEUROPULMONARY AMOEBIASIS
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As
far back as 1939 when Ochsner and DeBakey1 wrote their classical
review on amoebiasis, it was recognised that the
treatment of pleuropulmonary amoebiasis was primarily
based on systemic amoebicidal drugs. Their recommendaion
for ultraconservaion in the management of such cases has
been supported by later workers like Webster2, Wilmot3 and Takaro4 All subsequent publications
on the subiect have also repeatedly and emphatically
stressed this.5-9 Thus a vast majority of patients with pleuropulmonary amoebiasis can be successfully managed by conservative non-surgical measures provided a timely diagnosis is made.9-12 The conservative management of amoebic pleuropulmonary involvement is similar to that of amoebic liver abscess and has been discussed in detail earlier. The response to therapy is considered good if there is complete remission of symptoms and signs, disappearance of E. Histolytica from sputum, pleural aspirate or stools, and radiological evidences suggesting regression of the lesions.13 To minimise the need for surgery the use a drug combinations has been advocated.14 Pleuropulmonary amoebiasis can be dangerous and may terminate fatally. Since it is completely curable, Takaro10 has suggested that that conservative should be initiated even on suspicion of an etiology without awaiting confirmation. Aspiration of associated liver abscess greatly facilitates the healing of pleuropulmonary amoebiasis1 especially if response to drug therapy has not been very saisfactory3 Pleuritis and sympathetic pleural effusion usually respond rapidly to systemic amoebicidal drugs. A small effusion is reabsorbed in the course of a few to a week and hence does not need aspiration. In the case of an amoebic empyema or a massive amoebic pleural effusion, repeated aspirations of as much fluid as possible hasten healing and prevent troublesome sequelae.3 Rarely the pus is so thick that it is difficult to aspirate. In such cases there should be no hesitation in instituting open drainage. Moreover if the volume of pus at successive aspirations does not diminish, drainage should be resorted to. In uncomplicated cases e.g. without secondary infection, the prognosis is fairly good and recovery is not followed by residual pulmonary disability. If secondary infection with bacteria should occur, appropriate systemic antibiotics with repeated aspirations should be tried first.3 Intercostal tube drainage 6,15 is indicated if the patients’ condition is deteriorating, though as far as possible, it should be avoided 3,4,8,9,15. However if conditions for intermittent aspiration are not fulfilled, continuous drainage intercostally or following a rib resection, must not be delayed more than about seven days. In long standing cases, thoracotomy with decortication6 of the empyema may be attempted,15 but should not be undertaken hastily, as even an apparently gross and irreversibly thickened pleura may resolve over a period of a month or so. 3 Amoebic pneumonitis, consolidation and even amoebic lung abscess16,17 usually respond to conservative drug treament alone. Amoebic lung abscess will, in addition, require posfural drainage, to ensure adequate evacuation of the pus. Since there exists a direct communication with the atmosphere, secondary infection of the lung abscess is quite common and specific antibiotics should be stared simultaneously to prevent a consequent delay in healing. Surgery, as far as possible, should be avoided. Only, in the case of subsequent bronchiectasis or fibrosis with persistence of the abscess cavity, thoracotomy with resection of the involved segment may be considered. Before surgery is undertaken, Wilmot3 recommends a long period of observation as improvement may continue for many months after completion of specific treatment. However, if there is no improvement with medical treatment as seen on repeat X-rays,14 one may resort to surgery. In a broncho-hepatic fistula, as there is adequate drainage of the amoebic pus with minimal pulmonary reaction, cure usually follows conservative measures and is uneventful.3,17 Postural drainage greatly facilitates evacuation of necrotic material. Sometimes bronchial suction, bronchoscopy and needle aspiration of an associated empyema or the liver abscess may he necessary. Even a broncho-biliary fistula often heals without the need for surgical intervention3,18 Very rarely, a persistent broncho-biliary fistula may constitute an indication for surgery.3,18 Massive aspiration of necrotic material secondary to rupture of the abscess can cause a fatal complication. It was found to be a common cause of death in a series of 144 cases of broncho-hepatic fistula reported by Valdez Ochoa et al.19 Surely, the outlook in a broncho-hepatic fistula is now excellent and it is extremely rare for the patients to 'drown' in the copius pus as reported in the above series. Thus, to summarise, the treatment of pleuropulmonary amoebiasis is predominantly conservative. Surgical intervention is only adjunctive to definitive medical treatment and should be kept to a minimum. Even as late as 19764surgical mortality of pleuropulmonary amoebiasis was an appalling 33%. With liver scanning facilities and serological tests becoming more routinely available, it is hoped that early diagnosis and the institution of adequate conservative treatment will reduce the need for surgery and improve the prognosis of patients with pleuropulmonary amoebiasis. References
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