Unusual Large And Multiple Liver Abscesses in Patient Recovered From COVID-19

During the second wave of the COVID-19, in April-May 2021, a number of COVID-19 patients presented with some unusual manifestations. We saw for the first time in last two months unusually large and multiple liver abscesses in fourteen patients after recovery from COVID-19 infection. Liver abscess (Pus formation in Liver) is commonly caused by a parasite known as Entamoeba histolytica (Picture attached) which is transmitted by contaminated food and water.

According to Prof. Anil Arora, Chairman, Institute of Liver Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, “What we found unusual was that after recovery from Covid within 22 days in patients who were otherwise immunocompetent had large areas of both lobes of liver filled with pus at multiple locations requiring drainage and hospitalization.”

Prof. Anil Arora, further added “These patients were of age group between 28-74 yrs, ten were males and four females. All patients had fever and upper abdominal pain and 3 patients also had associated lower GI bleeding with black coloured stools. Eight of these patients received steroids for the management of COVID-19 symptoms. Six patients had multiple large abscesses in both lobes of liver of which 5 patients had unusually large abscess (>8cm) the largest being 19 cm size (Figures attached). Three patients who had blood in stools showed ulcers in large intestine which were detected by colonoscopy (large intestine were seen through a camera). Median duration between COVID-19 symptoms and diagnosis of liver abscess was 22 days. Thirteen out of Fourteen patients were successfully treated with antibiotics, Metronidazole medications and drainage of pus from the liver. While one patient with large multiple abscesses died due to massive bleeding in abdomen after rupture of abscess in the abdominal cavity. Rest are stable and have been discharged.”

Prof. Anil Arora also said that “In our patients we found multiple and large abscesses which is very unusual for an immunocompetent person. We believe that suppression of immunity by COVID-19 infection along with use of steroids to treat Covid infection per se, low index of suspicion for liver abscess and delay in treatment in patients recuperating from Covid in this pandemic probably led to development of multiple and large abscesses in Liver.”

Entamoeba histolytica is a common parasite in countries with poor sanitation services. This parasite causes amoebiasis, an intestinal infection that is also called amoebic dysentery. After an infection has occurred, the parasite may be carried by the bloodstream from the intestines to the liver and causes liver abscess. Normally these abscesses are single and not very large and picked up early on routine ultrasonography of the abdomen as a part of workup for fever and associated symptoms in immunocompetent patients. Poor nutrition, immunocompromised status (like in HIV and cancer patients) and steroid use predisposes patients to these infections by amoeba causing liver abscesses.

In this present pandemic, a high index of suspicion of such infections in the form of fever and pain in right abdomen merits a timely intervention in the form of an early diagnosis and effective medical therapy can effectively save uncalled misery and avoidable hospitalization in these patients, said Dr. Praveen Sharma, Senior Consultant Gastroenterology, Sir Ganga Ram hospital.