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Look beyond the obvious - II

Greetings of the day!

Dear Friend.
Today another story from Saudiarabia

Down the track of Memories

King Abdul Aziz specialist hospital Taif Saudi Arabia

On another occasion, Mr Zahrani (name changed), a 43 year old business man  presented with right upper abdominal pain  associated with loss of appetite of ten  days duration.
Clad in long Abaya, the anxious wife of Mr. Zahrani  kept her dazzling, branded ladies purse aside and pulled the CT scan report of her beloved husband and a referral note.

"Daktoor( doctor) we are worried" ,she said.

The  CT scan abdomen was suggestive of a hyper dense  lesion in the segment V  of liver and the concerned radiologist had mentioned lot of differentials below for further studies.
The differentials varied  from  a benign to malignant lesions of the  liver.
Loss of appetite was a worrying clinical symptom in this patient and Mr Zahrani was admitted for further evaluation.
The family was counselled about fine needle aspiration of this hyperdense lesion in the liver .
Next morning, in the wee hours  we shifted the patient to the radiology dept. The   fine needle aspiration was carried out under all aseptic precautions . The slides were immediately prepared by Mr Farooq Ahmad senior Microbiology technologist who was  working as supervisor of this CAP accredited laboratory.
Soon after the procedure our team went to attend  the morning report meeting in the blue colored Adminstrative block of the hospital . The morning report used to be a  great learning activity in the hospital as  over night admissions were briefed in this meeting in front of all medical specialities, followed by discussion of one interesting case.
That day our patient was  discussed .
The house was fully in support of a malignant lesion in this patient and all were of the opinion to have Fine needle aspiration for the final diagnosis.

Soon after the meeting we  straight away went to the   Microbiology dept in the ground floor of the hospital and we  met  Dr Manzoor Ahmad  Banday, the senior microbiologist.

Dr Manzoor  pulled up his specs  and went on demonstrating  the slides of the patient on a, 3 headed teaching microscope of the Dept.

"Look! This is a  classical anchovy sauce pus and these are swarming  Entameobea histolytica" while focusing minutely on the high power of the microscope Dr Manzoor said . There is  neither malignancy nor metastasis, he jubilantly concluded.
The hyperdense lesion was a solid organized abscess which had sparkled doubts of malignancy /metastasis  in the treating team and the radiologist.
CT image was not a  classical abscess.

We were thrilled to break this happy news to the family.
Normally the diagnosis of Amoebic liver abscess is quite straight forward in an endemic area but in a hyperdense lesion other differentials need  to be considered.
Amoebic liver abscesses  are  rare in Saudi Arabia because there is excellent sanitation and a stringent quality control of restaurants. These liver lesions develop  due to poor sanitation and unhygienic conditions. The transmission from restaurants is well known.
The patient was started on Metronidazole and 10 days later Mr Zahrani happily went his home.

Dear Friends : This    case     emphasizes the importance of fine needle aspiration which is a safe and useful diagnostic procedure for evaluating various lesions in Liver, spleen  and other organs of the body.