Amoebic liver abscess is a common condition. Lately this diagnosis is being made early and thus the complications of this illness are becoming rare. We present below an iatrogenic complication of this illness.

Material and Methods

Case 1: A 30 year old male presented in May 1986 for pain in right hypochondrium, swelling and a feeling of being unwell for last three months.

Three months prior to his present complaints, he was treated in a teaching hospital as a case of liver abscess and was tapped on two occasions. On examination, he had swelling in the right hypochondrium (Fig 1), which appeared to be in the soft tissues of anterior abdominal wall in the vicinity of the puncture marks of the liver tapping.

Liver was not enlarged. W.B.C. count was normal, but E.S.R. was 85 mm (Westergren) at the end of one hour. Serum alkaline phosphatase was normal. X-ray Chest was normal. Sonography confirmed abscess in the form of a sonolucent area in the anterior abdorninal wall. C.T. Scan was done. It showed osteomyyelitis of the 11th rib with an abscess in the anterior abdominal wall (Fig 2). Also a residula abscess was visualised at the junctional area if the liver. The patient was operated upon by the surgeon. Drainage of the anterior wall swelling was done. The rib was scooped and the scraping of the rib was sent for histopathology. The latter confirmed the diagnosis of osteomyelitis though no amoeba were seen. Postoperatively the patient received a full course injection of of emetine, chloroquine and broad spectrum antibiotics and recovered completely.

Case 2: A 36 year old male was admitted in a teaching hospital in November 1985, as a case of acute abdomen. On the operaIion. table, he was found to have a ruptured right lobe inferior surface amoebic liver abscess which was drained. Post operatively, he had a drainage tube in the right hypochondrium. Patient was discharged as "cured" On 20th January, he was readmitted for dull ache and swelling with a discharging sinus in the right hypochondriurn at the site of the drainage tube. He was discharged after twenty days.

In April 1986, he presented to one of us (OPK) for the sarne chronic persistent discharging sinus with a soft tissue swelling (Fig. 3) around it. X-ray Chest was normal. Sonography showed a normal liver, but a sonolucent area in the anterior abdominal wall consistent with an abscess. C.T. Scan was done. It showed appearances consistent with osteornyelitis of the 11th rib on the right side with an abscess in the abdominal wall (Fig. 4). The liver was normal. On the operation tablet scooping of the 11th rib was done and the scraping was sent for histopathology. The latter confirmed the diagnosis of osteomyelitis though no amoebae were seen. The patient recovered after polytherapy consisting of Injections of emetine, a course of chloroquine and broad spectrum antibiotics.

Discussion

Amoebic liver abscess is one illness where there are multiple complications. In the monograph on Amoebic Liver Abscess, I discussed about a dozen complications and reviewed hundred references all over the world. I did not come across a single case oi amoebic osteomyelitis of the right lower ribs. Thus this seems to be the first report in the world literature. It appears that in both the cases, it was produced iatrogenically. In the first patient, during the tapping on two

occasions, trauma and infection was introduced into the 11th rib on the right side. In the second case, post-operative drainage tube was the cause of infection spreading to the rib.

Since both the patients had received anti amoebic drugs, there was no question of finding amoebae in the scraping of the ribs. But for CT scan, this diagnosis would have been missed , as it was already missed ever after sonography was done. C.T. imaging has the advantage of showing the soft tissue and the bones as well.

It is therefor possible that in the past, this complication has not been detected, as all the irnaging procedures are still very new and their application in various diseases and complications is still being found out everyday.

Acknowledgment

We thank the Dean J.J. Hospital got allowing us to publish the above material.

REFERENCES

1. Kapoor O.P.— Amoebic Liver Abscess, Page 177, S S Publishers 1979.