This syndrome was first described by me in 1978. [l, 2] I was highly impressed by the unique presentation of the patient. At that time several thoughts crossed my mind. Such a patient would not land up with a gastroenterologist. Would a chest physician or a cardiologist be confident enough to diagnose such a ease and aspirate this strategically located abscess, in time to prevent sudden death?

Based on experience of five such eases, I devoted a chapter on this syndrome in my monograph on "Amoebic Liver Abscess". [5] While Lancet [4] and British Medical Journal [5] gave rave reviews on the book, the reviewer in Annals of Internal Medicine'; after appreciating the monograph gave the following sarcastic comment—"It is unfortunate that the author chose to break up a straightforward clinical presentation into a morass of complex clinical syndromes—the author has defined 19 separate clinical syndromes culminating in the U.S.S.S.L.L.A.L.A. Syndrome . . . Reading 60 pages of his clinical approach to the subject made me glad that my problem was reviewing the book and not learning its content". Since then I had second thoughts on this syndrome.

The following case is the sixth case described in the world literature, whom l treated at Jaslok Hospital recently. After going through this case report, any reader will be convinced that this syndrome should be labelled as a separate, distinct entity.

CASE REPORT

A 58-year old male presented in my clinic in October 1983 for symptoms of pain in left lower chest, precordium, epigastrium and fever of 15 days duration. On asking a leading question - he said he had felt pain in the left shoulder and trapezius area in the beginning of the illness, which he discarded as a "Sprain". There were no other symptoms like cough or diarrhoea to pinpoint the source of fever and pain. On examination the only physical signs were marked tachycardia of 160 per minute (with minimal fever), epigastric tenderness (no lump) and a shifted cardiac apex beat. The latter was seen in the fifth left intercostal space half an inch outside the nipple line but the left nipple was also pulsating forcefully. These physical signs present in a barrel-shaped chest (where normally one would not expect to see even a normal cardiac impulse) were significant. On fluoroscopic examination in my clinic, I found the left dome of the diaphragm markedly elevated and immobile and a peculiar angulation of the heart on the left cardiac border. These signs were later confirmed on X-ray Chest (Fig. 1). E.C.G. was absolutely normal except for showing marked Sinus Tachycardia. Routine blood count in my clinic showed presence of mild anaemia of 11 G Hb and Leucocytosis of 22,000 with 82% Polvmorphs.

With the above physical signs and findings, I admitted this case at Jaslok Hospital as a case of U.S.S.S.L.L.L.A.L.A. Syndrome for urgent liver aspiration to prevent sudden death from a rupture into the pericardium. An urgent liver scan done showed a cold area (Fig. 2) in the superior surface

With the above physical signs and findings, I admitted this case at Jaslok Hospital as a case of U.S.S.S.L.L.L.A.L.A. Syndrome for urgent liver aspiration to prevent sudden death from a rupture into the pericardium. An urgent liver scan done showed a cold area (Fig. 2) in the superior surface of left lobe. I.H.A. test was strongly positive in dilution of 1:2048. Sonography examination was not immediately available.

The patient was put on anti-amoebic drugs. An aspiration was done in the high epigastrium (inspite of no lump being present) with the needle pointing upwards (Fig. 3) and 200 ml of chocolate coloured pus was aspirated which on examination was sterile.

Although the patient improved dramatically his signs persisted and pulse was still 120 per minute. Sonographic examination was done (Fig. 4). A second aspiration was done and 600 ml of pus was aspirated. Before the patient was discharged, his latest X-ray Chest showed a normal left dome of the diaphragm (Fig. 5), and a normal vertical heart. A small amount of air could be seen (post aspiration) in the area of the abscess. The apex beat was now not seen and the pulse rate was normal. There was no epigastric tenderness and the patient made all uneventful recovery.

DISCUSSION

Less often an amoebic abscess can occur in the left lobe. In the past such abscesses were described as pointing downwards and rupturing into the peritoneal cavity resulting in acute abdomen [7]

It has also been described that the abscess can also rupture into the pericardium and the patient may present as a case of pericardial effusion. I noticed in the autopsy room, that a few patients died a sudden death without a diagnosis of even a pericardial effusion being made. These patients had an al)scess in this strategic location which ruptured acutely into the pericardium causing sudden death. After studying such cases I came to the conclusion that only if these patients could be diagnosed in one stage earlier, the sudden death could be prevented. [3]

Unfortunately, the title of the syndrome U.S.S.S. L.L.L.A.L.A. was criticized by most of the physicians who heard it. I would now like to justify this title - 'U' stands for "Uncomplicated" because unlike an Amoebic Pericarditis, the rupture of such an abscess is sudden. The next stage is death and the patient is seen only in autopsy room.

The first 'S' stands for "Superficial". Figure 6 will convince anyone that basically such abscesses are superficial and they advance upwards and not downwards. The clinical and radiological signs in the above ease, of the "pushing" of the heart (Fig. 1 and Fig.7) before and after the aspirations will confirm the upward movement of the abscess located in this position. Therefore, the lower half of the left lobe remains normal. The second and third 'S' stand for Superior Surface. The first 'L' stresses the point that this abscess is in the 'lateral' part of the left lobe. This anatomical location it is important to stress (Fig. 7) because in medial left lobe (developmentally) I have described a similar abscess, which is labelled as a junctional abscess. The second and third 'L's stand for "Left Lobe".

The last letters "A.L.A." stand for "Amoebic Liver Abscess". The word "Syndrome" is the most important because no specialist will pick up such a clinical haphazard combination of physical signs and symptoms unless described as a syndrome. In our country if a patient complains of left lower chest pain and has epigastric pain and tenderness, left shoulder pain, if his fluoroscopic examination shows elevated immobile left dome of diaphragm, white cell count is elevated, an urgent liver scan and/or sonography must be done. An urgent aspiration done boldly is life saving.

Though it is very rare to pick up this syndrome in clinical practice and though I saw my sixth case after a period of four years, I am convinced that the title of U.S.S.S.L.L.L.A.L.A. Syndrome is justified. If this syndrome is missed, next the patient is going to present only in the autopsy room!

A case report of an uncomplicated superior surface left lobe amoebic liver abscess has been described. It is suggested that such patients should be labelled as U.S.S.S.L.L.L.A.L.A. Syndrome. It has been also discussed that though sounding difficult, this title is justified.

REFERENCES

1. KAPOOR O. P.: Paper read at Annual Conference of Society of Nuclear Medicine of India at Madras in October 1978.
2. KAPOOR O. P.: Paper read at XIX Annual Conference of Indian Society of Gastroenterology at Simla in November 1978.
3. KAPOOR O. P.: Amoebic Liver Abscess, S. S. Publishers, 1979.
4. The Lancet 1: 631: 1980.
5. British Medical Journal 1: 171: 1980.
6. Annals of Internal Medicine 92: 578: 1980.
7. LAMONT N. M. and POOLER N. R.: Quart. J. Med. 1958, 27, 389.
8. ADMAS E. B. PROC. International Conference on Amoebiasis 1975 830 ed. by Sepulveda B and Diamond L. S. Institute Mexicano Del. Segaro Social, Mexico 1976.