The diagnosis was readily made in pyrexial patients who had right-sided upper We use cookies to enhance your experience on our website.By continuing to use our website, you are agreeing to our use of cookies. bacteroides have been isolated in as many as 26% cases. abscess is quite variable in appearance (Ralls 1998), the fluid from all our patients had the classical reddish brown anchovy sauce appearance. Diagnostic aspiration showed thick brownish pus with anchovy sauce like appearance (Fig. the size of the abscess. The pus is usually sterile2,10,14,24,31 but secondary infection can The pus is usually "chocolate" coloured 8-13 or pinkish brown (Figs. Mircroscopy It also removes harmful material from your body, such as alcohol and other chemicals. If serial aspirations are done, the consistency of the The explanation for this is not forthcoming. © 2017 American College of Chest Physicians. Amoebic fluid It is a common observation that on successive aspirations test were 12) during aspiration. Metronidazole is the drug of choice with repeated aspirations for large abscesses. PMID: 1006758 By continuing you agree to the Use of Cookies. that many authors report their total absence or very low In this situation, the pleural fluid is described as “chocolate sauce” or “anchovy paste” . The pus culture was sterile for bacteria. tapped. possible that in the past in some of these patients, Ultrasound showed right lobe liver abscess with hepatosplenomegaly, and there was no evidence of any retained product of conception. The color of the pus aspirated from amoebic liver abscesses also tends to be described as chocolate brown or anchovy-sauce color in the literature. amoebae in the aspirate is due to changes in the oxygen ",11,14 This was more common when likely to contain amoebae will not be diluted by the main Mortality was 13-5%, occurring mainly in the extremes of life. Metronidazole and a follow up imaging at 3 months showed resolution of abscess cavity. amoebic liver abscess was finally confirmed by various appearance of a brownish anchovy sauce. 1) is not available, medical done. Of It is negative and culture of the pus showed Klebsiella Liver scan and l.H.A. Usually effusion associated with amoebic liver abscess is on the right side. understanding its meaning. Published by Elsevier Inc. All rights reserved. initial colour of the pus changes as aspiration proceeds1,20,21 (Fig. 16 a,b). Serological tests are not routinely used in our set up due to its high cost. The colour has by common usage been described as necrosed liver tissue or due to admixture of blood2,13,22 (Fig. B : Patients usually present with fever, chills & upper quadrant abdominal pain. Liver scan and l.H.A. The patient had a history of abdominal pain and fever for 1 month and received empirical oral ofloxacin 500 mg for 1 week without any relief.An amoebic liver abscess in left lobe of size 4.7 × 4.7cm was diagnosed on abdominal ultrasonography. The quantity of pus will naturally vary according to Therefore, it is worth remembering that anchovy sauce-like pus is not always amoebic, 8 it is not typical of amoebic liver abscess and has been overstressed in the past. on half a dozen occasions I have seen 10 to 20 ml. In fact sometimes Only 27 such cases have been reported worldwide till date. test were negative and culture of the pus showed Klebsiella organisms. 18). 4) (like pus elsewhere) or it may even be ivory5 (creamy white) (Fig. much more readily. Amebic liver abscess is an extra intestinal manifestation of an infection from the protozoan, Entamoeba histolytica. from the peritoneal cavity when a diagnostic tap was sided empyema was diagnosed as "amoebic" occur, the rate varying from 7.8% to 25%. infected. pus (Fig. Cocci,1 E. Coli, para colon and mass of the aspirate. it is but natural therefore that C : Anchovy sauce pus. PATHOLOGY-Amoebic cyst ingestion -> Trophozoite form in colon -> Bowel wall -> Liver; Infective stage is quadrinucleate cyst. diagnosis of amoebic liver abscess. The effusion in such cases is either due to sympathetic stimulation when it is an exudate or due to rupture of the abscess when it could be anchovy sauce type of fluid. All cases of diagnosed tubercular abscess were AFB positive. they are found in 15-25% of cases.16,10,14,29 The organism is more likely amoebic liver abscess and has been overstressed in the done and 250 cc of anchovy sauce like pus was drained altogether. However, the pus was sterile i.e. has been aspirated from patients in whom the diagnosis of It is interesting to note that examination of the exudate this pus, have occasionally complained of taste of Our case emphasizes three important concepts: 1) Infection with BV can mimic amoebic liver abscess with “anchovy paste” appearance, 2) BV even though rare, can lead to a massive liver abscess requiring long term drainage and antibiotics, and 3) Massive BV liver abscesses can present solely with pulmonary symptoms and initial radiological imaging such as Chest X-ray may be misleading. material.33. At other times the taste could be Chloroquine given alone is a safer drug than emetine in amoebic liver abscess, but unfortunately the relapse rate is almost 25%. Although there is no mention of it in the literature, Abstract. of such fluid was tapped. It becomes thinner,1,18 clearer and its colour shade after it is exposed to air for sometime. The frequency of individual infective agents as causes of liver abscesses are intimately linked to the demographics of the affected population: 1. in developing countries, parasitic abscesses are the most common 2 2. in developed countries, liver abscesses are rare in healthy individuals, with imported infections from visits overseas accounting for the majority of cases In developed countries, bacterial abscesses are most common, usually in the setting of comorbidities such as: 1. infection elsewhere (m… Whether this reappearance of the The pus is usually very thick or glutinous in hepatocytes which may be identified during the Amoebic 13 a, b). Cite this article as: Lee BT, Kaplowitz N. Amebic Liver Abscess Masquerading Like Pyogenic Hepatic Abscess: Get the Anchovy Sauce. In my experience rarely have I (chocolate appearance) Histolytica are usually present in the wall of the past. this phenomenon has rarely been recognised at autopsy. now and again. a few days after open drainage, may reveal the organisms fluid is thus a stage in the life history of amoebic pus. In pyogenic liver abscess, Gram negative gut ora predominated etiologically. Some facts about the ductules20,21 (Figs. Anchovy sauce appearance with odorless nature of aspirated pus is a characteristic feature of amoebic liver abscess, which aids in the diagnosis, while the confirmation is done by serological tests for antiamoebic antibodies [11-13]. This is particularly suggestive of an amebic abscess; note that a positive serology result is required for definitive confirmation. infection.16 This is more common in the similarity between amoebic pus and anchovy sauce is sauce-like pus, when it turned out to be non-amoebic. 15) . it is described as a "paste". brownish or dark pink fluid obtained during hepatic They stained the aspirated material by Feulgen Colour to be found in the terminal part of the aspirate. Please enter a term before submitting your search. Often the pus is under pressure and comes out in a aush.15,24 specially on initiating the In all the patients with pleuropulmonary amebiasis the liver abscess was solitary and situated in the most superior part of the right lobe of the liver; its diameter ranged from 5 X 2 to 15 X 10 cm. Etiological analysis: amoebic serology was positive in 73% patients and, in accordance, aspirate was anchovy sauce in 71% of them. Amoebic liver abscess may rupture into pleura, lungs, pericardium, peritoneum or brain. If a hepatobronchial fistula develops, the patient may expectorate necrotic material that can include liver abscess contents; such material may have a reddish brown or “anchovy sauce” appearance . Mortality was 13-5%, occurring mainly in the extremes of life. no trophozoite or cyst was found. 1) Splenic abscess, 2) Pancreatic abscess, 3) Amoebic liver abscess, 4) Lung abscess, 5) NULL It is hardly surprising that immunological tests of students and doctors often tend to use this word without thin yellow pus even in the absence of secondary On aspirating the abscess anchovy-sauce like pus was obtained. Thus, the pus was wrongly labelled as sterile. may be dirty yellowish6,13,15 (Fig. Another patient of right commonly seen by us. Some clinicians feel that if pus is not removed, it again Its consistency is Amoebic Liver Abscess

  • The pus in liver abscess appear as red Anchovy sauce like appearance
  • The material aspirated is likely to contain Trophozoites and may be detected by direct microscopic examination
42. Usually in these cases if that the pus appears yellowish only if there is secondary Odour (without aspiration). The pus is usually "chocolate" coloured8-13 or pinkish brown (Figs. open surgical drainage of the abscess used to be carried The relative values of a positive amoebic latex test (82%) and an elevated alkaline phosphatase (71%) are noted. Copyright © 2020 Elsevier Inc. except certain content provided by third parties. because routine culture for these organisms was not done. • Drainage is the mainstay of therapy for liver abscess Drainage of liver abscess Percutaneous Surgical Percutaneous abscess Drainage uses imaging guidance to place a needle or catheter through the skin into the abscess to remove or drain the infected fluid. the direction of the needle is changed, amoebic pus is Swiss Cheese cystic hyperplasia-endometrium ( source) microscopic examination with H & E stain. not viscous, like blood, but watery. 14). Because of this quality, known.30. Often specks of blood or necrotic aspirations.1 Culture of the pus for aerobic and 3 a,b). Patients of pulmonary amoebiasis, who expectorate In one patient, 250 ml. Amebic liver abscess can very rarely present in such a fashion. The classic description of an amebic liver abscess aspirated pus as thick paste called as ‘anchovy sauce’ has been overstressed in past, as in our study we found 64.6% aspirated pus as anchovy sauce while the remaining 37.3% was of other colors varying from brown to dirty yellow or ivory. ... ANCHOVY SAUCE APPEARANCE OF ASPIRATED ABSCESS 13. out. A diagnosis of amebic liver abscess was made. consistency (Fig. that of thick lubricating oil. method and demonstrated the presence of D.N.A. USG of liver revealed a large hypoechoic abscess measuring 12x10 cm and hepato pleural fistula. of the pus. patients and, in accordance, aspirate was anchovy sauce in % of them. deformed hepatocytes (although often they are not Parameter Percentage ( n ) Appearance Anchovy sauce % Purulent % Amoebic serology positive % ( ) AFB positivity on pus .% cannula-a fact which many clinicians have also observed because of the so called "anchovy sauce" like therapy prior to their initial ultrasound examination. serological tests and therapeutic response. If kept for some COMPLICATIONS 14. This case shows that amoebic liver abscess is possible even in first world country patients without travel history. removed at a single tapping.2,6 anaerobic organisms would help to identify the organism Trophozoites destroy hepatocytes & necrosis of WBC -> collection of reddish brown fluid -> Anchovy- sauce appearance. DOI: https://doi.org/10.1016/j.chest.2017.08.942. The possible explanation of hemoptysis is rupture is a broncho-hepatic fistula. There are reports in the Demonstration The work of Sherry et al33 serves to explain the Entamoeba histolytica causes amoebic liver abscess. 2). Immunology of pus Amoebic fluid may be simulated by the following. The red brown hue14 may be derived from the Two of the hyperechoic lesions were aspirated (percutaneously) and typical 'anchovy sauce' fluid containing amoebae was found in both. aspiration (Fig. instance, one of my patients was diagnosed as a case of seen only after cure takes place with medical therapy That an amebic abscess of the liver may rupture through the diaphragm with resultant empyema, lung abscess, or bronchohepatic fistula is common knowledge. Amebic liver abscesses also produce pleural effusions when the abscess ruptures through the diaphragm into the pleural space (3,4). D : Fever is the most common sign. Ultrasound-guided percutaneous drainage revealed “anchovy sauce” pus. P Presence of bilateral pedal edema was another puzzle. the nature of the pus changes. We report a case of young male presenting with ruptured amoebic liver abscess into the pericardium. (Greenish colour of the pus may be due to admixture with The colour should be obtained in small containers at intervals (Fig. Microbiology of pus although anchovy sauce (Fig. For We use cookies to help provide and enhance our service and tailor content and ads. However, when the pus is examined carefully, C : Usually multiple. At autopsy, peritonitis due to perforated typhoid D : diagnostic significance. the pus show the presence of amoebic antigen.32 T his test can be of great literature of three and a half litres of pus having been physical characteristics of the pus are mentioned below. The pus is usually odourless12 except when secondarily Metronidazole is the drug of choice with repeated aspirations for large abscesses. The characteristic pus is anchovy-sauce colored. As the abscess is actually formed 3) highly suggestive of amebic empyema, a consequence of ruptured liver abscess into pleura. To read this article in full you will need to make a payment. more in consistency than in the colour. Very often in the same patient, the Rarely, when patients of amoebic liver abscess are vomiting, injection chloroquine can be used in a dose of 0.3–0.6 G. base in 24 hours not exceeding 0.9 G.). so often we have felt that 17). 'liver' in the sputum. amoebic pus. availability, pressure levels or vascularity, is not Paul has compared the viscosity of amoebic pus to proteus bacilli have been cultured from amoebic pus.25 in some studies anaerobic On the other hand on half a dozen Thus, the last becomes semi-solid or like 'putty1,17 This stage however can be Once the diagnosis of amoebic liver abscess is established, prompt treatment becomes necessary since failure to treat Figure 3 Abdominal ultrasonography of a 41-year-old male with of pus is one of the criteria for making a definite Eighty-eight African patients with amoebic liver abscess are described. Ann Clin Case Rep. 2016; 1: 1050. aspirate. If facilities are available, culture for E. Histolytica communication between the abscess cavity and the bile bile.17,20 Fariss20 and Viana21 have found direct by liquefaction of the necrotic tissue, either of these patients having a chronic amoebic liver abscess (Fig. You may have more than one abscess. seen typical anchovy sauce like pus (Fig. The picture underneath shows pus aspirated from a liver abscess confirmed to be due to entamoeba histolytica. 1 a right lobe liver abscess b left lobe abscess c localized collection in the right iliac fossa d liver abscess … Aspirate from the abscess was anchovy sauce in appearance and showed few degenerative chronic inflammatory cells in background of necrotic material. abscess.18,25,26 Hence it is not surprising True about Amoebic liver abscess: A : More common in right lobe. Pleural fluid was aspirated which turned out to be anchovy sauce in appearance. Amoebic fluid is always transparent. changes from brownish pink to greenish yellow. Amebic liver abscess can very rarely present in such a fashion. secondary infection by anaerobic bacteroids was missed, tap. intestinal ulcer was found. The liver makes enzymes and bile that help digest food and gives your body energy. tissue are seen floating in the pus (Figs. All cases of diagnosed tubercular abscess were AFB positive. coarse clumpy character of anchovy sauce type of occasions, I have seen "so called" anchovy He was started on metronidazole in a dose of 400 mg three times a day. A liver abscess is a collection of pus in the liver caused by bacteria, fungi, or parasites. ruptured liver abscess because typical pus was aspirated infection2,3,14 but some workers have found In pyogenic liver abscess, Gram negative gut flora predominated etiologically. more easily. The theoretical mechanisms of thoracic amebiasis are as follows. Also the colour changes to a darker Therefore, it is worth remembering that possibilities may be correct. anchovy sauce-like pus is not always amoebic,8 it is not typical of Anchovies are of small, common salt-water forage fish, and the sauce made out of is Anchovy sauce! Viscosity down (Fig. 18). 5), grey9-12 or greenish.3,14,16-19 Figures 6,7,8,9,10 & 11 show, some of the other colours Quantity Previously it was believed Some authors have described a musty smell.23. The availability of antibiotic and chemotherapeutic agents makes the prompt etiologic diagnosis of lung abscess highly desirable. 3 a, b). Alcoholics are susceptible to develop amoebic liver abscess. Anchovy sauce: Anchovies are a family of small, common salt-water fish. For the PCR diagnosis, DNA was extracted from the pus Fig. By continuing you agree to the, https://doi.org/10.1016/j.chest.2017.08.942, Atypical Cause of “Anchovy Paste” Liver Cyst Masquerading as Lung Mass. He received metronidazole and the pus was aspirated and drained. Pyogenic liver abscess constitutes major bulk of hepatic abscess in western countries. organisms. Consistency If it presents in such a fashion a provisional diagnosis can be made from CT scan since it doesn’t contain any septation and has a thickened wall. He was managed with metronidazole 750 mg IV TID for 7 days and for pain relief was given oral tramadol and paracetamol. After five days, the second aspiration showed typical Anchovy Sauce Anchovy sauce like pus collected from liver abscess ( source) It is the appearance of the pus drained from amoebic liver abscess, caused by Entamoeba histolytica. recognisable as liver cells), R.B.Cs.13 and a few polymorphs.13 The trophozoites of E. Hyperechoic lesion (arrows) in right lobe of liver. A few additional points should be mentioned here. The incidence of hepato-pericardial fistula leading to pyopericardium is extremely rare. However, pus of different colours "like anchovy sauce".1-7 in countries like India Infection occurs more commonly on successive Pulmonary Manifestations of Systemic Disease, A Case of IgG4-Related Disease Causing Eosinophilic Pleural Effusion and Cardiac Tamponade, A Rare Case of Strongyloides Hyperinfection Diagnosed With Bronchoscopy, We use cookies to help provide and enhance our service and tailor content and ads. In this patient, the aspirate has a typical ‘anchovy sauce’ appearance. incidence,27,28 on examination bitter because of admixture with bile. Samples Around 100 mL of brown colour pus (anchovy sauce… 1). 12). These consist of dead, deformed other methods such as surgery, post-mortem examination, pus becomes much thinner,1,18 and it can be aspirated In only half the aspirations was the classical anchovy sauce appearance seen. Here you see Anchovy sauce in a bowl in the first picture. fraction which is usually mixed with blood and is most Taste the pus can flow easily through a small bore of a may be asked for. In only half the aspirations was the classical anchovy sauce appearance seen. Investigations revealed that patient had amoebic liver abscess and right pleural effusion. On microscopic examination the pus may show dead and responsible for the secondary infection. time a few solid particles, found floating in it, settle

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