Amoebic Liver Abscess Presenting Thirty-Two Years after Acute Amoebic Dysentery

G B, man aged 50 History: Admitted February 1974 with a oneweek history ofrigors, continuing fever (38-39°C), malaise, anorexia and generalized aches and pains. Treated at home with ampicillin. He was born in Burma and lived in the Far East until 1963 when he settled in England. He smokes up to 60 cigarettes a day, drinks little alcohol and gave a past history of malaria (last attack 1962). On examination: Pyrexial (39°C) with a few coarse crepitations at both bases. Liver just palpable but not tender. Investigations: ESR 125 mm in 1 hour (Westergren). Hb 12.0 g/100 ml. No malarial parasites seen. WBC 20 300/mm3 (neutros. 90(%); alkaline phosphatase 18.0 K-A units/100 ml (later 25 K-A units); albumin 3.1 g/100 ml (later 3.4). Chest X-ray showed old calcified lesions of right upper zone of lung. Blood cultures, mid-stream urine, extended Widal and antinuclear factor tests all negative. Treated initially with co-trimoxazole and his temperature settled. Further questioning revealed that he had had acute amoebic dysentery in 1942, and in view of his raised phosphatase, a liver scan was performed. This showed a single large spaceoccupying lesion in the middle of the right lobe (Fig 1A). Serology (Dr A L Jeanes): Fluorescent amoebic antibody test positive (initially at a titre of 1:64, later 1:256). Hydatid CFT, a-fetoprotein, hepatitis B antigen, autoimmune profile and examination of stools all negative.