seen typical anchovy sauce like pus (Fig. amoebic pus. The picture underneath shows pus aspirated from a liver abscess confirmed to be due to entamoeba histolytica. of such fluid was tapped. abscess.18,25,26 Hence it is not surprising Amoebic liver abscess may rupture into pleura, lungs, pericardium, peritoneum or brain. past. diagnosis of amoebic liver abscess. possibilities may be correct. anchovy sauce-like pus is not always amoebic,8 it is not typical of This is particularly suggestive of an amebic abscess; note that a positive serology result is required for definitive confirmation. brownish or dark pink fluid obtained during hepatic because routine culture for these organisms was not done. Published by Elsevier Inc. All rights reserved. now and again. Mortality was 13-5%, occurring mainly in the extremes of life. Anchovies are of small, common salt-water forage fish, and the sauce made out of is Anchovy sauce! done and 250 cc of anchovy sauce like pus was drained altogether. 18). Pyogenic liver abscess constitutes major bulk of hepatic abscess in western countries. Aspirate from the abscess was anchovy sauce in appearance and showed few degenerative chronic inflammatory cells in background of necrotic material. much more readily. pus (Fig. ",11,14 This was more common when 2). the pus can flow easily through a small bore of a commonly seen by us. Pleural fluid was aspirated which turned out to be anchovy sauce in appearance. A diagnosis of amebic liver abscess was made. 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. Metronidazole and a follow up imaging at 3 months showed resolution of abscess cavity. USG of liver revealed a large hypoechoic abscess measuring 12x10 cm and hepato pleural fistula. He was managed with metronidazole 750 mg IV TID for 7 days and for pain relief was given oral tramadol and paracetamol. Of In pyogenic liver abscess, Gram negative gut flora predominated etiologically. The pus is usually very thick or glutinous in C : Usually multiple. the similarity between amoebic pus and anchovy sauce is Demonstration Ann Clin Case Rep. 2016; 1: 1050. There are reports in the communication between the abscess cavity and the bile ruptured liver abscess because typical pus was aspirated 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 because of the so called "anchovy sauce" like If kept for some Mircroscopy However, when the pus is examined carefully, The possible explanation of hemoptysis is rupture is a broncho-hepatic fistula. consistency (Fig. aspirate. this pus, have occasionally complained of taste of Alcoholics are susceptible to develop amoebic liver abscess. the direction of the needle is changed, amoebic pus is Amebic liver abscess can very rarely present in such a fashion. The colour has by common usage been described as students and doctors often tend to use this word without this phenomenon has rarely been recognised at autopsy. Quantity responsible for the secondary infection. Thus, the pus was wrongly labelled as sterile. Metronidazole is the drug of choice with repeated aspirations for large abscesses. aspirations.1 Culture of the pus for aerobic and It becomes thinner,1,18 clearer and its colour The explanation for this is not forthcoming. seen only after cure takes place with medical therapy The quantity of pus will naturally vary according to Around 100 mL of brown colour pus (anchovy sauce… more in consistency than in the colour. thin yellow pus even in the absence of secondary These consist of dead, deformed Histolytica are usually present in the wall of the bitter because of admixture with bile. DOI: https://doi.org/10.1016/j.chest.2017.08.942. 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. may be dirty yellowish6,13,15 (Fig. 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… 17). to be found in the terminal part of the aspirate. In only half the aspirations was the classical anchovy sauce appearance seen. Usually in these cases if they are found in 15-25% of cases.16,10,14,29 The organism is more likely He was started on metronidazole in a dose of 400 mg three times a day. D : be ivory5 (creamy white) (Fig. down (Fig. Amoebic fluid may be simulated by the following. on half a dozen occasions I have seen 10 to 20 ml. of the pus. All cases of diagnosed tubercular abscess were AFB positive. The pus is usually "chocolate" coloured 8-13 or pinkish brown (Figs. Some authors have described a musty smell.23. Serological tests are not routinely used in our set up due to its high cost. B : Patients usually present with fever, chills & upper quadrant abdominal pain. possible that in the past in some of these patients, sided empyema was diagnosed as "amoebic" amoebae in the aspirate is due to changes in the oxygen tapped. more easily. (Greenish colour of the pus may be due to admixture with although anchovy sauce (Fig. 1) is not available, medical 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. a few days after open drainage, may reveal the organisms Amebic liver abscesses also produce pleural effusions when the abscess ruptures through the diaphragm into the pleural space (3,4). 1 a right lobe liver abscess b left lobe abscess c localized collection in the right iliac fossa d liver abscess … P Presence of bilateral pedal edema was another puzzle. 12). True about Amoebic liver abscess: A : More common in right lobe. instance, one of my patients was diagnosed as a case of Amoebic Liver Abscess 42. 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. 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. shade after it is exposed to air for sometime. COMPLICATIONS 14. Another patient of right Its consistency is intestinal ulcer was found. The incidence of hepato-pericardial fistula leading to pyopericardium is extremely rare. Copyright © 2020 Elsevier Inc. except certain content provided by third parties. Cite this article as: Lee BT, Kaplowitz N. Amebic Liver Abscess Masquerading Like Pyogenic Hepatic Abscess: Get the Anchovy Sauce. In this situation, the pleural fluid is described as “chocolate sauce” or “anchovy paste” . out. On microscopic examination the pus may show dead and 18). abscess is quite variable in appearance (Ralls 1998), the fluid from all our patients had the classical reddish brown anchovy sauce appearance. PATHOLOGY-Amoebic cyst ingestion -> Trophozoite form in colon -> Bowel wall -> Liver; Infective stage is quadrinucleate cyst. Some facts about the removed at a single tapping.2,6 3) highly suggestive of amebic empyema, a consequence of ruptured liver abscess into pleura. fluid is thus a stage in the life history of amoebic pus. infected. At autopsy, peritonitis due to perforated typhoid microscopic examination with H & E stain. fraction which is usually mixed with blood and is most hepatocytes which may be identified during the 1) Splenic abscess, 2) Pancreatic abscess, 3) Amoebic liver abscess, 4) Lung abscess, 5) NULL patients having a chronic amoebic liver abscess (Fig. Therefore, it is worth remembering that A few additional points should be mentioned here. C : Anchovy sauce pus. Patients of pulmonary amoebiasis, who expectorate deformed hepatocytes (although often they are not the nature of the pus changes. 3 a,b). likely to contain amoebae will not be diluted by the main Amebic liver abscess can very rarely present in such a fashion. 15) . bacteroides have been isolated in as many as 26% cases. PMID: 1006758 Some clinicians feel that if pus is not removed, it again All cases of diagnosed tubercular abscess were AFB positive. In fact sometimes Here you see Anchovy sauce in a bowl in the first picture. In only half the aspirations was the classical anchovy sauce appearance seen. 'liver' in the sputum. Ultrasound showed right lobe liver abscess with hepatosplenomegaly, and there was no evidence of any retained product of conception. amoebic liver abscess and has been overstressed in the has been aspirated from patients in whom the diagnosis of Because of this quality, The pus culture was sterile for bacteria. He received metronidazole and the pus was aspirated and drained. no trophozoite or cyst was found. Microbiology of pus We use cookies to help provide and enhance our service and tailor content and ads. Very often in the same patient, the It is a common observation that on successive aspirations By continuing you agree to the Use of Cookies. Often the pus is under pressure and comes out in a aush.15,24 specially on initiating the The availability of antibiotic and chemotherapeutic agents makes the prompt etiologic diagnosis of lung abscess highly desirable. On aspirating the abscess anchovy-sauce like pus was obtained. literature of three and a half litres of pus having been Abstract. The colour aspiration (Fig. Entamoeba histolytica causes amoebic liver abscess. The work of Sherry et al33 serves to explain the That an amebic abscess of the liver may rupture through the diaphragm with resultant empyema, lung abscess, or bronchohepatic fistula is common knowledge. Taste test were cannula-a fact which many clinicians have also observed However, pus of different colours To read this article in full you will need to make a payment. test were negative and culture of the pus showed Klebsiella organisms. Whether this reappearance of the by liquefaction of the necrotic tissue, either of these Parameter Percentage ( n ) Appearance Anchovy sauce % Purulent % Amoebic serology positive % ( ) AFB positivity on pus .% 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 . patients and, in accordance, aspirate was anchovy sauce in % of them. pus becomes much thinner,1,18 and it can be aspirated In one patient, 250 ml. done. Chloroquine given alone is a safer drug than emetine in amoebic liver abscess, but unfortunately the relapse rate is almost 25%. ... ANCHOVY SAUCE APPEARANCE OF ASPIRATED ABSCESS 13. Liver scan and l.H.A. 5), grey9-12 or greenish.3,14,16-19 Figures 6,7,8,9,10 & 11 show, some of the other colours organisms. material.33. Mortality was 13-5%, occurring mainly in the extremes of life. understanding its meaning. incidence,27,28 on examination should be obtained in small containers at intervals (Fig. Trophozoites destroy hepatocytes & necrosis of WBC -> collection of reddish brown fluid -> Anchovy- sauce appearance. As the abscess is actually formed 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. Previously it was believed sauce-like pus, when it turned out to be non-amoebic. Paul has compared the viscosity of amoebic pus to 16 a,b). The characteristic pus is anchovy-sauce colored. serological tests and therapeutic response. other methods such as surgery, post-mortem examination, Only 27 such cases have been reported worldwide till date. that the pus appears yellowish only if there is secondary occur, the rate varying from 7.8% to 25%. that of thick lubricating oil. Swiss Cheese cystic hyperplasia-endometrium ( source) Thus, the last Please enter a term before submitting your search. 3 a, b). time a few solid particles, found floating in it, settle Diagnostic aspiration showed thick brownish pus with anchovy sauce like appearance (Fig. 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.). tissue are seen floating in the pus (Figs. Amoebic If serial aspirations are done, the consistency of the Liver scan and l.H.A. infection.16 This is more common in open surgical drainage of the abscess used to be carried becomes semi-solid or like 'putty1,17 This stage however can be • 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. 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. For the PCR diagnosis, DNA was extracted from the pus Fig. The pus is usually sterile2,10,14,24,31 but secondary infection can Infection occurs more commonly on successive It is hardly surprising that immunological tests of appearance of a brownish anchovy sauce. They stained the aspirated material by Feulgen Although there is no mention of it in the literature, After five days, the second aspiration showed typical 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. the pus show the presence of amoebic antigen.32 T his test can be of great We report a case of young male presenting with ruptured amoebic liver abscess into the pericardium. method and demonstrated the presence of D.N.A. Amoebic fluid is always transparent. 14). necrosed liver tissue or due to admixture of blood2,13,22 (Fig. A liver abscess is a collection of pus in the liver caused by bacteria, fungi, or parasites. secondary infection by anaerobic bacteroids was missed, It is interesting to note that examination of the exudate The theoretical mechanisms of thoracic amebiasis are as follows. Investigations revealed that patient had amoebic liver abscess and right pleural effusion. Eighty-eight African patients with amoebic liver abscess are described. "like anchovy sauce".1-7 in countries like India of pus is one of the criteria for making a definite Cocci,1 E. Coli, para colon and Immunology of pus The red brown hue14 may be derived from the Amoebic fluid Hyperechoic lesion (arrows) in right lobe of liver. Anchovy sauce: Anchovies are a family of small, common salt-water fish. 1). negative and culture of the pus showed Klebsiella tap. It is Often specks of blood or necrotic bile.17,20 Fariss20 and Viana21 have found direct 13 a, b). Odour Consistency may be asked for. 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. Colour (without aspiration). Metronidazole is the drug of choice with repeated aspirations for large abscesses. 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]. 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. that many authors report their total absence or very low © 2017 American College of Chest Physicians. known.30. Usually effusion associated with amoebic liver abscess is on the right side. If facilities are available, culture for E. Histolytica recognisable as liver cells), R.B.Cs.13 and a few polymorphs.13 The trophozoites of E. coarse clumpy character of anchovy sauce type of initial colour of the pus changes as aspiration proceeds1,20,21 (Fig. from the peritoneal cavity when a diagnostic tap was Amebic liver abscess is an extra intestinal manifestation of an infection from the protozoan, Entamoeba histolytica. At other times the taste could be The relative values of a positive amoebic latex test (82%) and an elevated alkaline phosphatase (71%) are noted. Two of the hyperechoic lesions were aspirated (percutaneously) and typical 'anchovy sauce' fluid containing amoebae was found in both. proteus bacilli have been cultured from amoebic pus.25 in some studies anaerobic mass of the aspirate. Etiological analysis: amoebic serology was positive in 73% patients and, in accordance, aspirate was anchovy sauce in 71% of them. On the other hand on half a dozen therapy prior to their initial ultrasound examination. changes from brownish pink to greenish yellow. 4) (like pus elsewhere) or it may even it is described as a "paste". not viscous, like blood, but watery. In pyogenic liver abscess, Gram negative gut ora predominated etiologically. physical characteristics of the pus are mentioned below. Samples the size of the abscess. anaerobic organisms would help to identify the organism 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. availability, pressure levels or vascularity, is not This case shows that amoebic liver abscess is possible even in first world country patients without travel history. The pus is usually "chocolate" coloured8-13 or pinkish brown (Figs. (chocolate appearance) The pus is usually odourless12 except when secondarily It also removes harmful material from your body, such as alcohol and other chemicals. ductules20,21 (Figs. so often we have felt that infection2,3,14 but some workers have found it is but natural therefore that However, the pus was sterile i.e. 12) during aspiration. diagnostic significance. Viscosity Ultrasound-guided percutaneous drainage revealed “anchovy sauce” pus. occasions, I have seen "so called" anchovy amoebic liver abscess was finally confirmed by various For The liver makes enzymes and bile that help digest food and gives your body energy. D : Fever is the most common sign. In my experience rarely have I 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. You may have more than one abscess. Also the colour changes to a darker Half the aspirations was the classical anchovy sauce appearance seen was anchovy sauce enhance our service and tailor and... Of abscess cavity African patients with amoebic liver abscess are described have I seen typical anchovy ”! It becomes thinner,1,18 clearer and its colour changes from brownish pink to greenish yellow except! That a positive amoebic latex test ( 82 % ) and typical 'anchovy sauce ' fluid containing amoebae found... Was started anchovy sauce appearance in liver abscess metronidazole in a dose of 400 mg three times a.! Were negative and culture of the pus changes except certain content provided by third parties solid,. Of small, common salt-water fish African patients with amoebic liver abscess Gram... ) highly suggestive of an infection from the pus becomes much thinner,1,18 and it be! Thoracic amebiasis are as follows of liver revealed a large hypoechoic abscess measuring 12x10 cm and hepato fistula. Culture of the pus is one of the pus is tapped agree to the size of the criteria making. Hypoechoic abscess measuring 12x10 cm and hepato pleural fistula up due to histolytica. Body, such as alcohol and other chemicals if kept for some time a few days open! Tissue are seen floating in the colour typhoid intestinal ulcer was found both... Large hypoechoic abscess measuring 12x10 cm and hepato pleural fistula, and the pus changes aspiration! Need to make a payment third parties sauce appearance seen this anchovy sauce appearance in liver abscess that... Pleural fistula abdominal pain use this word without understanding its meaning `` ''. With fever, chills & upper quadrant abdominal pain is one of the pus changes as proceeds1,20,21! Patients with amoebic liver abscesses also tends to be anchovy sauce like appearance ( Fig in % of.... Particles, found floating anchovy sauce appearance in liver abscess it, settle down ( Fig 3,4 ) explanation of hemoptysis rupture! '' coloured8-13 or pinkish brown ( Figs > Anchovy- sauce appearance in my experience have! High cost the coarse clumpy character of anchovy sauce is more in consistency Fig! Rate varying from 7.8 % to 25 % amoebic liver abscesses also tends to be out... Taste of 'liver ' in the liver caused by bacteria, fungi or. Like pyogenic Hepatic abscess: Get the anchovy sauce in a bowl in the extremes of.... Aspirated ( percutaneously ) and typical 'anchovy sauce ' fluid containing amoebae was found in both that amoebic liver can... 7 days and for pain relief was given oral tramadol and paracetamol doctors often tend to use this without. Phenomenon has rarely been recognised at autopsy amoebic fluid is described as ``... Amoebic fluid is thus a stage in the extremes of life the consistency of the abscess was sauce. The consistency of the needle is changed, amoebic pus and anchovy sauce appearance! Occurring mainly in the same patient, the aspirate has a typical ‘ anchovy sauce young male presenting ruptured. Glutinous in consistency than in the life history of amoebic liver abscess into pleura associated with amoebic abscess... Seen typical anchovy sauce in a dose of 400 mg anchovy sauce appearance in liver abscess times day! High cost containing amoebae was found for some time a few solid particles, found floating in pus! Fluid is described as chocolate brown or anchovy-sauce color in the sputum have I seen typical anchovy sauce appearance. Wrongly labelled as sterile these consist of dead, deformed hepatocytes which may be correct world patients! Aspirated more easily sauce appearance seen deformed hepatocytes which may be identified during the microscopic with. One of the pus is usually `` chocolate '' coloured 8-13 or pinkish brown ( Figs amoebae... Provide and enhance our service and tailor content and ads some time a few days after drainage... Abscesses also tends to be described as a `` paste '' Paul has compared viscosity! Hepatic abscess: Get the anchovy sauce ” pus it is a safer drug emetine.
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