Indian Journal of Thoracic and Cardiovascular Surgery, 1984; 3:67-69

Clinico-Pathological Conference-3

An young adult male was hospitalised in a moribund, toxic state after a brief episode of fever and epigastric pain. He had features of constrictive pericarditis. Chest X-rav on ad- mission showed Pneumopericardium He had not undergone any investigation prior to admission.

Fig. I. 5kir gram of the chest ott admissio.

68

Spontaneous Pneumopericardium due to Rupture of Amoebic Liver Abscess into Stomach and Pericardium SOLOMON VICTOR, V. JAYANTHI AND N. MADANAGOPALAN

KFY WORDS: Pneumopericardiurn, amoebic; pericarditis, amoebic'.

OPERATIVE FINDINGS

Emergency thoracotomy revealed inflamma- tion of both the layers of pericardium. The parietal pericardium was excised leaving a strip parallel to the phrenic nerve. About 200 ml of purulent material was evacuated from the pericardial cavity. There was a layer 1 mm thick covering the heart which was peeled away. An irregular deficiency with shaggy edges was seen in the left dome of diaphragm. Diaphragm was incised. An inflamed omentum was seen plugging the defect in diaphragm and also a large perforation in the anterior wall of the stomach. Inflamed tissue was surrounding the left lobe of the liver. The operative findings suggested an amoebic abscess of left lobe of liver which had ruptured into the stomach and pericardium leading to spontaneous pneumo- pericardium and constrictive pericarditis. Ob- viously the abscess had drained into the sto- mach. The perforation into the stomach and diaphragm was plugged with omentum. Biopsy of stomach wall showed amoebae.

From the Departments of Cardiothoracic Surgery and Gastroenterology Government General Hospital, Madras, India.

Address for Correspondence:

Solomon Victor 15 East Street Kilpauk Garden colony Madras-600 010, India

DISCUSSION

Quijano Pitman et ai I described necropsy findings in amoebic pericardial involvemept in 1790. Morehead 2 in 1856 described liver abscess with complications involving pericar- dium and peritoneum. In 1859, Miguel Jime- nez 3 made the first clinical diagnosis of liver abscess rupturing into the pericardium. Rouis 3 in 1860 described an autopsy case of amoebic pericarditis, Robert Koch 4 in 1887 showed the relation of amoeba to liver abscess. Germil- ton 3 in 1899 is credited with the first clinical diagnosis of amoebic pericarditis.

Fig. 2 Operative photograph showing peel of visceral pericardium (white triangle) and Ryles tube (black triangle passing through perforation in stomach.

Pneumopericardium Amoebic 69

Abscess in left lobe of liver tends to rupture early because o f the smaller mass of liver tissue 4. Amoebic abscess originating in the left lobe o f liver reaches the pericardium by direct invasion. Right lobe lesion of liver seldom invades the pericardium. Even when a right lobe abscess is present, an associated left lobe abscess may be responsible for the pericardial invasion 3. Sometimes the pericardium is involved secon- dary to an empyema or from an amoebic lung abscess 4. Progressive pericardial t amponade is a c o m m o n clinical presentation o f rupture into the pericardiumL Cardiac arrhythmia could occur due to myocardial involvement 3. Con- strictive pericarditis may develop. The abscess may also rupture into the peritoneal cavity, left pleural cavity, or the lung.

Lamontand Pooler 6 report seven cases o f abscess rupturing into pericardium with morta- lity o f 70%. Localised abscess could occur in the subphrenic space, infrahepatic space or [esse! sac 7.

The treatment of choice in these cases is immediate pericardiocentesis, followed as soon as possible by open pericardiotomy 8 and drai- nage o f liver abscess.

Amoebic oesophageal lesions and gastritis have been described following swallowing of material f rom amoebic broncho-hepat ic fistula 4. Stomach and duodenum were involved in 210 postmortem cases o f amoebiasis 9. Abscess o f liver which ruptures into the stomach or in- testine generally heals rapidly. Gastric dis- placement is c o m m o n with left lobe liver abs- cess. It may be displaced forwards or posteri- orly 3. The stomach may show a concave or cresentric deformity or sickle appearance3. Lesser curvature may be stretched and roundedL Filling defect in fundus of the s tomach has also been described s. The duodenal bulb may be displaced downwards with medial displacement

of the second part of duodenum. The intra- abdominal port ion o f oesophagus may be elongated and displaced posteriorly 3.

Pericardial involvement can lead to the follow- ing3: (a) Suppurative pericarditis (acute or chronic); (b) Sympathetic, non-suppurat ive pericarditis; (c) Constrictive pericarditis; and (d) amoebic hydropneumoper icardium. The latter is due to simultaneous rupture into sto- mach and pericardium. Adams (quoted by Kapoor 3) and Kapoor O.P 3 have each reported one case. Rupture into stomach appears to be rare possibly because o f its thick wall. The present case is reported for its rarity.

References

1. QUIJANO PITMAN F, FLAMAND E, IBARRA PEREZ C AND ARUGUERO SAN("HEZ R. Amoebic Periearditis In: Scpulveda B and Diamond LS eds. Procee- dings o f the International Cott[erence o f Amoebiasis Inst. Mex. dcl Seguro Social, Mexico, 1976; p 826.

2. MOREHEAD G. Clinical researches on diseases in India. Vol I & II Brown, Green and Longmans, India. 1856.

3. KAPOOR OP. Amoebic liver abscess. Bombay: S.S. Publishers, 1979; p 75-82, 87-92.

4. VAKIL B J, VAKIL N. Amoebic Disease--A Treatise. Bombay : Basic & Business Publications, 1983 ; p 114.

5. VERGtlESE M, EGGLESTON FC, HANDA AK, SINGH CM. Management o f thoracic amebiasis. J Thorac Cardiovasc Surg 1979; 78: 757-60.

6. LAMON'r NM POOLER NR. Hepatic amoebiasis, a studyof250cases. QuartJ Med 1958; 27:389-412.

7. RASARATNAM R WIJETILAKA SE Left lobe amoebic liver abscess. Med J 1976; 52:269.

8. CORONET L. Treatment o f intrapericardial rupture o f amoebic abscess o f liver by pericardiotomy com- bbzed with medial laparotomy. J Chir (Paris) 1973; 105:269-72.

9. MATOES .IH. Cerebral amoebiasis. J Neurosurg 1964;21:704.