January 1990, Volume 40, Issue 1

Case Reports

AMOEBIC PERICARDIAL EFFUSION - DIAGNOSIS SUGGESTED BY ULTRASONOGRAPHY

Durr-e-Sabih  ( Pakistan Atomic Energy Medical Centre and Nishtar Medical College and Hospital, Multan. )
Sher M. Khan  ( Pakistan Atomic Energy Medical Centre and Nishtar Medical College and Hospital, Multan. )
M. Inayatullah  ( Pakistan Atomic Energy Medical Centre and Nishtar Medical College and Hospital, Multan. )
Zahida Sabih  ( Pakistan Atomic Energy Medical Centre and Nishtar Medical College and Hospital, Multan. )

Amoebic pericardial effusion is a very rare site of extra- intestinal amoebiasis. We present a case where sonographic features suggested the diagnosis.

CASE REPORT

A 35 years old male presented with a two months history of progressively increasing dys­pnoea. On examination he was in respiratory distress, afebrile, had prominent neck veins and an increased area of cardiac dullness. The heart sounds were muffled, and the abdomen was un­remarkable except for an enlarged, tender liver. The blood count was normal, but the ESR was raised (60mm). X-ray chest showed an enlarged heart shadow.
A clinical diagnosis of a pericardial effusion was made and he was sent to this Centre for echo-cardiography which showed a large pericar­dial effusion with a swinging heart (Figure 1). A routine upper abdominal ultrasonography study revealed a 9cm hypoechoic, oval lesion with a strongposterior enhancement in the left lobe of the liver. There were dilated tubular structures nearby (Figure 2). The appearance was that of a left lobe liver abscess. The concurrence of these findings prompted us to suggest a diagnosis of an amoebic liver abscess leading to pericardial effusion. As­piration of both the pericardial cavity and the liver lesion yielded identical pinkish fluid. The fluid was sent for pathological examination and though vegetative amoebae were not found, the patho­logist agreed with our impression of an amoebic etiology on the basis of the gross appearance. Serological tests for amoebiasis were, however, strongly positive. The patient was put on an­tiamoebic drugs and had a rapid response. Sub­sequent examinations showed lessening of both the pericardial and hepatic lesions and by five months of follow-up, there was complete resolution.

DISCUSSION

Pericardial effusion of amoebic origin is so rare that it merits no more than apassing reference in many textbooks of medicine1-6. From 1899 to 1978, only 137 cases have been described in the world literature7. When present, the symptoms of sub-sternal pain, discomfort and respiratory dis­tress are super- imposed on those of the hepatic abscess8-10. Our patient was unusualin that he had no abdominal symptoms except for a vague upper abdominal pain and a slightly tender, enlarged’ liver. His primary complaint was of progressive dyspnoea.
The combination of an upper abdominal sonography study with echocardiography pointed to a plausible diagnosis which was confirmed by aspiration and therapeutic response. The charac­teristic appearance of the fluid aspirated would have led to the correct diagnosis eventuallybut our contribution probably expedited the process.
We cannot make any recommendations on the basis of a soth:ary case but would like to point out that an experienced sonologist needs no more than a few minutes to scan the upper abdomen if it is normal, and making it a habit can yield unex­pected but valuable clinical information in cardiac cases.

ACKNOWLEDGEMENT

The authors are grateful to the following individuals for their help in the preparation of this paper.
Dr. A. Rauf Khan, Abha, Saudi Arabia and Hafiz Ghulam Abbas, Julich, W. Germany for literature survey. Mr. Akhtar Hussain for secre­tarial assistance and Mr. Masood Ahmed for illustrations.

REFERENCES

1. Weatherall, DJ., Ledingham, J.G. and Warrell, D.A. ed. Oxford textbook of medicine. Oxford, Oxford University Press, 1984, P. 12,219.
2. Stein, J.H. ed. Internal medicine. Boston, Little Brown, 1983, p. 1450.
3. Wyngaarden,J.B.and Smith, L.H. Jr.ed.Cecil; textbookof medicine. 17thed. Philadelphia, Saunders, 1985, p. 830.
4. Warren, KS. and Mahmoud, A. ed. Tropical and geographical medicine. NewYork, McGraw-Hill, 1984, p. 311.
5. Petersdorf,R.G.,Adams, RD., Braunwald,E,Isselbacher, KJ., Martin,J.B. and Wilson,J.D. Harrison’sprinciplesof internal medicine. lOthed. NewYork, McGraw-Hill, 1983, p. 864.
6. Braunwald, B. ed Heart disease. 2nd ed. Philadelphia, Saunders, 1984, p. 1474 (t).
7. Pericardial Amoebiasis, 1978. J. Assoc. Physicians India, 1978; 937 (Editorial).
8. Sabistan, D.C. Jr. ed. David-Christopher’s textbook of surgery. 12th ed Philadelphia, Saunders, Philadelphia, 1981, p. 1209.
9. Watson, RB., Steel, R. K.,Spiegel,T.M.Amoebic pericarditis consequent to amoebic abscess of right lobe of the liver. Am. J. Trop. Med. Hyg., 1972; 21: 889
10. Mahmood, S., Khan, M.A., Nishtar, T. Amoebic pericardial effusion. JPMA., 1988; 38: 86.

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