PLEUROPULMONARY
COMPLICATIONS OF AMEBIASIS

ALTON OCHSNER, M.D.
and
MICHAEL DEBALKEY, M.D.
New Orleans, Da.
From the Departments of Surgery, Tulane Uni-

versity School of Medicine, Touro Infirmary,
and Charity Hospital

Reprinted from
THE JOURNAL OF THORACIC SURGERY
St. Louis

Vol, 5, No. 8, Page 225, February, 1936

(Printed in U7. S. A.)

 

 
PLEUROPULMONARY COMPLICATIONS OF AMEBIASIS
AN ANALYSIS oF 153 COLLECTED AND 15 Prersonan Cases*

Auron Ocusner, M.D., anp Micnar, DeBaxey, M.D.
New Or.eEAns, La.

NTIL relatively recently amebiasis attracted little attention in non-
tropical localities; although as early as 1902 Sir Leonard Rogers*
demonstrated that complicating hepatie abscess, which previously had
been designated ‘‘tropieal abseess,’’ occurred in other than tropical
climates. The recent epidemic of amebiasis has more forcefully empha-
sized its ubiquitous distribution; although it is our opinion that the
actual incidence of amebiasis in temperate climates probably has not in-
creased in recent years. According to the authoritative opinion of
Colonel Craig,? 10 per cent of the people of this country habor the
Endameba histolytica, and frequently the diagnosis of amebiasis is over-
looked because of the mildness of the clinical manifestations.

Amebiasis is of significance to the surgeon because of the relatively
high incidence of hepatic and the less frequent ineidenee of pulmonary
suppuration. The importance of pleuropulmonary complications of ame-
biasis cannot be sufficiently appreciated without some knowledge concern-
ing the high incidence of hepatic amebie abscesses, because thoracic com-
plications are generally the result of extension of the suppurative process
in the liver through the diaphragm into the thorax. In a previous study on
amebic hepatic suppuration we® collected 4,392 fatal cases of amebiasis,
of which 387.9 per cent (1,664 cases) were complicated by hepatic suppu-
ration. In our study there were 59 clinical cases of amebic abscess of the
liver among 388 cases of amebic dysentery admitted to the Charity Hos-
pital in New Orleans during the six-year period 1928 to 1933, inclusive,
an incidence of 15.2 per cent. Seven (13.5 per eent) of our 59 eases of
amebie hepatic abscess were complicated by extension of the suppurative
process to the thorax with involvement of the lung in 6 and the pleural
cavity in 1. Pleuropulmonary amebie¢ infections are second to hepatie

*From the Departments of Surgery, Tulane University School of Medicine, Touro
Infirmary, and Charity Hospital.

Read before the Eighteenth Annual Meeting of the American Association for
Thoracic Surgery, New York, June 8, 4, and 5, 1935.

3
lesions as complications of amebiasis. The present report is based on a
study of 15 cases of pleuropulmonary complications of amebiasis ad-
mitted to the Charity Hospital in New Orleans from January 1, 1928, to
April 1, 1935, and an analysis of 153 cases collected from the literature.

Historical—According to Lemierre and Bernard,’ Pringle in 1752,
Portal in 1813, Larrey in 1829, Budd in 1845, and Cambay in 1847 ob-
served cases in which hepatic abscesses, probably amebie, ruptured into
the pleural cavity. Similar cases were observed by Duplay® in 1829 and
by Behier® in 1836. Gaillard,’ in 1856, reported a ease of abscess of the
liver with perforation into the pleura and the pericardium. Rouis,® in
1860, reported that in 162 autopsies on patients with amebie abscess of
the liver 11 had perforated into the pleura. Other eases of historical
interest are included among the collected eases analyzed in the present
study (Hospel,® Rouis,’ Foiret,’° Bellot,1t Gouran,? Morvan,!* De-
bergues,’* Gueschwind,'® Simon, Lafleur,!? Ferrhon,’* Bertrand and
Fontan’ and Osler.?°

Incidence.—The frequeney of pulmonary complications in amebiasis
varies considerably according to different statistics. The incidence re-
ported by different authors varies from 3 per cent in Strong’s' series of
100 fatal eases of amebiasis in which the lung was involved once and the
pleura twice, to 58.8 per cent of 170 cases reported by Thierfelder.2? In
a series of 2,490 reported amebic hepatic abscesses, pleural complications

TABLE I

INCIDENCE OF PLEUROPULMONARKY COMPLICATIONS IN REPORTED SERIES

 

 

 

 

 

CASES OF LIVER | LUNG COMPLI- PLEURAL COM-
ABSCESS CATIONS PLICATIONS

Clark2s 95 5

Craig24 22 1 7
Waring? 300 15 28
Dutroulan26 66 7 10

Roux27 162 14 17
Hospel9 25 2
Cambay28 10 2
Futcher29 27 9 3
Sambuc30 102 7 4
Murray and Koh31 23 4

Strong? 100 1 2
Thompson32 27 7 4
Rendu33 563 31
Harris34 95 3
Talbot35 15 1
Vergoz-Hermemjat-Gerin36 80 28
Thierfelder22 170 74 26

Cyr37 563 59 31
Manson-Bahr38 45 5

2,490 209 ( 8.38%) 198 (7.5%)

Authors3 95 10 (10.2%) 5 (5.2%)

 

 

 
oceurred in 198 (7.5 per cent) and pulmonary complications in 209 (8.3
per cent) (Cases 3, 9, 21, 22, 28-38) (Table T). Of 95 consecutive cases
with amebie hepatie abscess admitted to the Charity Hospital and the
Touro Infirmary in New Orleans from January 1, 1928, to April 1, 1935,
15 (15.7 per cent) had pleuropulmonary complications. In 7 (7.3 per
cent) the hepatie abscess perforated into the lung, in 5 (5.2 per cent)
into the pleura, and in 3 (3.1 per cent) there was a bronchopleural
fistula. The total incidence of pleuropulmonary complications in our
series (15.7 per cent) is practically the same as that obtained in the eol-
lected series (15.8 per cent) (Graph 1).

 

INCIDENCE OF
PLEUROPULMONARY = COMPLICATIONS
OF AMEBIC HEPATIC ABSCESS

207

[[] PLEURAL COMPLICATIONS
MMM PULMONARY COMPLICATIONS

 

 

 

Graph 1.—Graph showing incidence of pleuropulmonary complications in collected
series and in authors’ series.

Pleuropulmonary amebic infections occur most frequently in the third
and fourth decades of life. In the collected series of cases there were 92
in which the age was stated. Of this group, 3 (3.2 per cent) were in the
second, 35 (88 per cent) in the third, 23 (25 per cent) in the fourth,
22 (23.8 per cent) in the fifth, 7 (7.5 per cent) in the sixth, and 2 (2.1
per cent) in the seventh decades (Graph 2). The youngest was four-
teen years old, the oldest sixty-two years, and the average age was thirty-
four and five-tenths years. In our series the youngest was twenty-one,

3
the oldest sixty-three, and the average age was forty and six-tenths years.
Three (20 per cent) were in the third decade, 3 (20 per cent) in the
fourth, 6 (40 per cent) in the fifth, 2 (18.3 per cent) in the sixth, and
1 (6.6 per cent) in the seventh decades. The majority of our patients
were approximately two decades older than in the collected cases
(Graph 3), a faet which we are unable to explain.

The sex incidence is similar, as would be expected, to that of amebic
abseess of the liver, i.e., a preponderant occurrence in males. In the
collected cases the sex was stated in 120, of which 115 (96.2 per cent)

 

INCIDENCE {IN COLLECTED CASES
40

ACCORDING TO AGE

30

20

     

 

   

10-19 20-29 30-39 40-49 50-59 60-69

 

Graph 2.—Graph showing age incidence in collected series.
AGE INCIDENCE ACCORDING TO DECADES
50 ~~. COLLECTED SERIES

~— AUTHOR'S SERIES

 

 

10-19 20-29 30-38 40-49 50-59 60~

Graph 3.—Graph showing comparison of age incidence in collected series and in
authors’ series.

were males and 5 (3.8 per cent) females. In our series there were 14
males and 1 female (Graph 4). This considerably higher incidence in
males is explained by the apparently greater susceptibility of males to
amebie abscess of the liver. In the collected cases there were 4 in which
it was stated the patient was colored and 14 were white. Presumably
the other 135 were white. In our scries of 15 cases there were 9 white
and 6 colored patients.

Etiology and Pathogenesis——Pleuropulmonary amebie involvement is

6
probably always secondary to amebiasis elsewhere and is generally the
result of extension of the process from an amebie infection of the liver.
Most, if not all, amebie infections begin in the large bowel, from which
area the amebas may be carried probably through the blood stream te
other parts of the body. As the intestinal tract is drained by the portal
vein, involvement of the liver oceurs relatively frequently. In most
instances the amebic infection of the pleura and the lungs is the result

 

   
   

SEX INCIDENCE
IN

00 PLEUROPULMONARY AMEBIASIS

l ~~

904 mz
MALES

sot |
FEMALES

7o+

60+

504

4o+

30+

204

lo 4

| [3.0%] |

 

 

 

 

COLLECTED AUTHORS’
CASES CASES

Graph 4.—-Graph showing sex incidence in collected series and in authors’ series.

of direct extension from an amebic hepatic abscess, perforation occurring
through the diaphragm into the lung, bronchus, or pleura. Rarely
transphrenic migration of the amebas from a subphrenic amebie process
to the thorax may occur without gross perforation. This according to
Loison®® is the result of amebas being earried in the diaphragmatic

7
lymphatics. Relatively rarely involvement of the pulmonary parenchyma
may oceur as a result of hematogenous infection, the amebas gaining
entrance to the lung either by the blood stream or through the lym-
phaties and blood stream. In the former, amebas may be carried through
the portal vein, hepatic capillaries, and hepatic veins to the vena cava
or through the anastomotic collaterals of the hemorrhoidal veins into
the vena cava (Petzetakis*®). In the latter the amebas may be carried
from the colon through the thoracie duct to the left subelavian vein and
hence to the lungs. Strong,?? on the other hand, is of the opinion that
the pleuropulmonary complications are never metastatic, but always
occur by direct extension from a liver abscess.

Rarely, if ever, primary amebic infection of the lung occurs. Pana-
yatalou and Netter*! described a case which they considered primary
amebic bronchitis. Petzetakis*? described 2 cases of amebic bronchitis in
which amebas were found in the sputum, one of which was not associated
with any bowel disturbance. A similar case was reported by Haber-
feld,*? who believes that although there is no history of amebie infec-
tion of the bowel, one is not justified in assuming such never was pres-
ent. In many of the reported cases a liver abscess and pulmonary
abscess occurred concomitantly without any apparent connection between
the two. The majority of amebie abscesses of the liver occur on the
convex surface and in the posterior portion of the right lobe; and as
the abscess enlarges, its periphery approaches the diaphragm, gradually
incorporating it in the wall of the abscess, facilitating the perforation of
the hepatic suppurative process into the thoracic cavity. In most in-
stances there is an accompanying pleurisy with adhesions which ob-
literate the pleural cavity, so that rupture occurs into the base of the
right lung. In those instances, however, in which extension of the
hepatic process is more rapid and in which there is no antecedent pleu-
risy, the abseess ruptures into the pleural cavity. Many times rupture
of an hepatic abscess into the lung produces relatively little inflam-
matory pulmonary reaction, the contents of the hepatic abscess being
evacuated through the communication between the liver abseess and a
bronchus. In such instanees the clinical manifestations rapidly subside,
especially under adequate therapy.

Pathology—There are a number of types of pleuropulmonary amebic
infections, and in our study of the collected cases we have divided the
lesions into five different groups, depending upon the type of the pleuro-
pulmonary involvement: (1) hematogenous pulmonary abscess without
liver involvement; (2) hematogenous pulmonary abscess and independ-
ent liver abscess; (3) pulmonary abscess extending from liver abscess;
(4) bronchohepatic fistula with little pulmonary involvement; (5)
empyema extending from liver abscess (Fig. 1). In our collected series
of 153 cases there were 22 in which the pulmonary amebic infection

8
occurred without liver involvement (Fig. 1). In one of these reported by
Panayatalou and Netter*? (Case 115), the amebie infection of the lung was
supposedly primary. In the other 21 the amebie infection was emboli¢
and secondary to a process in the colon. Kofoid, Boyers, and Swezy**
believe that hematogenous transportation of amebas occurs more fre-
quently than is generally supposed. In the investigations in fatal cases
they found amebas in practically every tissue of the body examined.
Strong,*? on the other hand, contends that amebie infections are never
embolic and believes in those eases in which a communication between the
hepatic abscess and the thoracie lesion cannot be demonstrated that

 

Fig. 1.—Diagramimatic representation of various types of pleuropuimonary amebic
infections. a, Hematogenous pulmonary abscess without liver involvement; 14.3 per
cent of the collected series and none of our cases were of this type. b, Hematogenous
pulmonary abscess and independent liver abscess. As illustrated in the drawing the
pulmonary process is separated from the hepatic process by normal lung: 10.4 per
cent of the collected series and none of our cases were of this type. ec, Pulmonary
abscess extending from liver abscess. In contrast to Group 2, intervening portion
of lung between pulmonary and hepatic process is involved; 37.2 per cent of the
collected series and 46.6 per cent of our cases were of this type. d, Bronchohepatie
fistula with little pulmonary involvement. In this type, communication between hepatic
abscess and bronchus is more direct and large, permitting evacuation of hepatic
abscess contents with little involvement of pulmonary parenchyma; 19.6 per cent of
the collected series and 20 per cent of our cases were of this type. e, Empyema ex-
tending from liver abscess. Because of absence of pleural adhesions, perforation of
hepatic process occurs inta pleural cavity; 17.6 per cent of the collected and 33.3
per cent of our cases were of this type.
the perforation has healed. In the collected series there were 16 cases
in which a hematogenous pulmonary abscess and a liver abscess oc-
curred concomitantly without any apparent communication between the
two (Fig. 1). There were 5 of the group of 16 cases in which a perfo-
ration of the liver abscess into the pleura or lung occurred, although
the original lung abscess in the 16 cases was supposedly hematogenous.
In 4 of these (Cases 77, 150, 151, 152) the liver abscess ruptured into
the pleural cavity; whereas in 1 (Case 57), the liver abscess ruptured
into the lung. In by far the greater majority of cases the amebic infee-
tion of the lung oceurs in the right lower lobe. This is probably due to
the fact that in most instances the infection gains entrance to the lung
by direct extension from the liver. In our previous study* on amebic
hepatitis we found the right lobe of the liver involved in 92.9 per cent.
Adhesions are usually present between the inferior surface of the right
lower lobe of the lung and the diaphragm and hetween the superior
surface of the liver and the diaphragm so that perforation of liver
abseess is usually directly into the lung or bronehus without passing
through the uninvolved pleural cavity. In cases with no limiting ad-
hesions, perforation of the liver abscess into the pleural cavity oecurs.
In the collected series of 153 cases there were 58 in which a liver abscess
had extended into the lung, producing amebie pneumonitis and abscess
(Fig. 1). In each series the pulmonary abseess was located in the lower
lobe. In our series 7 of the 15 were of this type. Oceasionally perfo-
ration of the liver abscess into the lung occurs in the region of a large
bronchus with the development of a bronchohepatie fistula which per-
mits adequate evacuation of the liver abscess and produces little reaction
in the pulmonary parenchyma (Fig. 1). Jn the collected series of 153
eases there were 30 patients with bronchohepatic fistulas and with little
or no pulmonary involvement. In our series there were 3 of this type
(Cases A 8, A 11, A 12). These cases must be distinguished from the
communicating hepatic and pulmonary abscesses in which there is also
a communication with a bronchus. In the collected series of cases there
were 27 in which a liver abscess was complicated by empyema (Fig. 1).
Tn our series of 15 eases, 5 were of this type. In those eases in which a
localized abscess in the inferior portion of the pleural cavity ecommuni-
cates with an abscess below the diaphragm, Pruvost*® deseribes the ab-
scess as a ‘‘shirt stud’’ abscess. Strong?! has described the amebie liver
abscess as being filled with a grayish yellow or yellowish red fluid mate-
rial. He differentiates between amebic pulmonary abscess and liver ab-
scess in that the walls of the former are less even than those of the latter.
In some areas the walls are smooth and are composed of connective tis-
sue. He describes three zones in the walls of the older abscesses, the
first, a necrotic one containing fragmented nuclei, degenerated cells, and
amebas. The second layer is composed of connective tissue fibers, epi-
thelial cells, elastic fibers, and groups of alveoli with occasional amebas.

10
The third consists of a layer of small round cell infiltration in which
fibrin and some proliferation of connective tissue fibers are visible be-
tween the alveoli. The walls of the bronchi in the region of the abscesses
are infiltrated with numerous round cells, and the bronchi usually con-
tain purulent or serous fluid. The contents of the abscess may vary
according to its type. In the hematogenous amebic abscess the contents
are purulent and are in no manner characteristic; whereas in those
eases in which a communication between the liver abscess and the pul-
monary or pleural lesion exists, the contents are usually chocolate sauce
pus.

Clinical Manifestations —Clinical manifestations of amcbic infections
of the lung and pleura vary according to the mode of the infection. In
those eases in which the infection extends from a liver abscess, the first
manifestation is usually a severe pain in the lower portion of the chest-
on the right side. This is undoubtedly due to the involvement of the
diaphragmatic pleura by the inflammatory process. Bernard*® has em-
phasized the importance of shooting pains at the right base accom-
panied by slight pyrexia. Pruvost** deseribes the pain as violent and
as being aggravated by respiration. The pain is frequently referred to
the right shoulder, a symptom which was especially emphasized by
Thompson.” A distressing, unproductive cough in the beginning, prob-
ably due to pleural involvement, is a prominent symptom. Expectora-
tion of large quantities of purulent material and particularly chocolate
sauce pus occurs in cases with communication between the abscess and
a bronchus. Dyspnea may oceur, especially in eases in which there is
a communication with a bronchus and in which there is considerable
encroachment upon a large portion of the lunge field. In the 153 col-
lected cases a statement was made concerning symptoms in 134. The
chief complaint was cough and expectoration in 87 (64.9 per cent),
fever in 24 (17.9 per cent), pain in the chest in 21 (15.6 per cent),
pain in the right upper quadrant in 15 (11.1 per cent), diarrhea in 13
(9.5 per cent), pain in the right shoulder in 4 (2.9 per eent), loss in
weight in 3 (2.2 per cent), dyspnea in 2 (1.4 per cent), malaise in 2
(1.4 per cent), swelling of the right chest in 1 (0.7 per cent), and weak-
ness in 1 (0.7 per cent). In our eases the chief complaints were as
follows: cough and expectoration in 6 (40 per eent), pain in the chest
in 6 (40 per cent), pain in the right upper quadrant in 4 (26.6 per
cent), fever in 1 (6.6 per cent), and pain in the right shoulder in
1 (6.6 per cent). Aside from the chief complaint there were other
symptoms described in 134 of the 153 collected cases. One hundred and
twenty-four (92.5 per cent) of these complained of cough and expec-
toration, 58 (43.2 per cent) of fever, 55 (41 per cent) of a previous
diarrhea (Graph 5). In 1 case a previous diarrhea was denied. Forty-
six patients (33.5 per cent) had diarrhea at the time of admission to
the hospital. Forty-two (81.3 per cent) had chest pain, Thirty (22.3

il
per cent) had pain in the right upper quadrant. Twenty-five (18.6
per cent) had cachexia. Twenty-one (15.6 per cent) had dyspnea.
Seventeen (12.6 per cent) had pain in the right shoulder. In our 15
patients all (100 per cent) had fever. Fourteen (93.3 per cent) had
cough and expectoration. Five (83.3 per cent) had pain in the chest.
Four (26.6 per cent) had pain in the upper right quadrant. Three (20
per cent) had pain referred to the right shoulder. Three (20 per cent)
had dyspnea. Only 2 (13.3 per cent) had had previous diarrhea, and
only 1 (6.6 per cent) had diarrhea during the present illness. Two
(13.3 per cent) were emaciated, and 1 (6.6 per cent) had chills. Pro-
fuse expectoration of chocolate sauce pus is pathognomonic in amebie
infections of the Iung and indicates rupture of amebie hepatic abscess
into a bronchus. In 74 instances of the 153 colleeted cases it was stated

 

100
80 CLINICAL MANIFESTATIONS
80 IN

COLLECTED CASES

 

 

 

COUGH; EXPEC- FEVER PREVIOUS. ENLARGED DIARRHEA cHest TENDER PAIN RUG CACHEXIA
TORATION DIARRHEA VER PAIN LIVER

Graph 5.—Graph showing incidence of clinical manifestations in collected cases.

definitively that chocolate sauce pus was present in the sputum. In the
majority of other instances no statement was made concerning the char-
acter of the expectorated material. In our series of cases chocolate
sauce pus expectoration was present in 14 cases, an incidence of 100 per
cent, as there were only 14 with bronchial communication. The fifteenth
case in our series was one with a perforation of the hepatic abscess into
the pleural cavity alone.

The chest findings are usually those of consolidation and cavitation.
As a matter of fact, in many instances a diagnosis of pulmonary tuber-
culosis is made erroneously. Dullness over the affected portion of the
lung is the most frequent pulmonary sign. Statements regarding phys-
ical signs were made in 134 of the 153 collected cases. In 33 of the
collected series and in 9 of our 15 eases there was thoracic dullness.

12
Rales were found in 17 of the reported cases and in 9 of our cases.
Diminished breath sounds were found in 9 of the collected cases and in
3 of our cases. In those relatively rare cases in which the liver abscess
first perforates into the pleural cavity with the development of an empy-
ema, the clinical manifestations are those of pleural effusion, ie., dull-
ness, diminished breath sounds, and limitation of motion of the involved
hemithorax. In addition to the thoracic manifestations the abdominal
manifestations of amebic infection are important. In the majority of
instances the liver is enlarged and tender. The liver was enlarged in
53 (39.7 per cent) and tender in 35 (26.1 per cent) of the collected
eases. The same signs were found in 6 (40 per cent) of our 15 cases.
The absenee of liver enlargement was explicitly stated in 5 of the col-
lected eases. The finding of concomitant involvement of the liver and
lung is suggestive of amebie pulmonary infection. In practically all

 

SPUTUM PUS

Graph 6.—Graph showing incidence of positive findings of amebas in sputun: and
pus of collected series. The percentages are based on the number in which a state-
ment was made concerning this examination.

cases there is a moderate pyrexia. Characteristically, however, as in
the amebie infections elsewhere in the body, the elevation of the tem-
perature is not high. In our serics of cases the highest temperature on
admission was 103° F. In the majority, however, it ranged between
100° and 101° F. Wyperpyrexia and chills in cases of amebie infections
of the pleura and lungs probably indicate secondary infection and are
not caused by the amebic infection per sc.

Laboratory Findings—As in amebiasis elsewhere in the body, a mod-
erate leucocytosis is usually encountered in amebic infections of the
pleura and lungs. In our previous publications® 47 we emphasized that
in amebie hepatic suppuration there is a moderate leucocytosis without
a concomitant increase in the polymorphonuclear leucocytes. In the
collected cases of pleuropulmonary amebie infections the highest leuco-
cyte count observed was 52,000, the lowest 9,700, the average 18,860.

13
The highest polymorphonuclear count was 91 per cent, the lowest 53
per cent, and the average 72.8 per cent. In our series of cases the high-
est leucocyte count was 51,250, the lowest 7,500, the average 17,000. The
corresponding polymorphonuclear percentages were 92 per cent, 70 per
cent, and 79 per cent, respectively. Obviously the leucocyte count and
polymorphonuelear percentage are not so high in amebie infections of
the lung as in corresponding pyogenic infections, especially pneumococcic.
In those eases of amebie infections of the lung which are accompanied
by high leucocyte and polymorphonuelear counts a secondary infection
probably has supervened. In recent pulmonary amebie infections, amebas
are generally present in the sputum and can be demonstrated by micro-
seopie examination. Petzetakis** emphasizes the importance of imme-
diate examination of the sputum. A moist, warm preparation is best
for the microscopic study. In the collected cases amebas were found in
the sputum in 19, and in 5 eases it was explicitly stated that amebas
were not present (Graph 6). In 7 of our cases the sputum was exam-
ined for amebas, and it was found positive in 2 (28.5 per cent). The
stools may or may not contain amebas or cysts. The reason there are
not more positive stool findings is that frequently the colonie amebic
infection has subsided by the time the pulmonary symptoms develop.
In the colleeted eases the stools were examined in 8, and amebas were
found in 2. According to Futcher,?® the sputum in these cases contains
pus cells, elastic tissue, hematoidin erystals, and occasionally Charcot-
Leyden erystals. Bernard? belicves that a diagnostie point in regard
to the sputum is the small number of organisms which are in the sputum
early in the condition, although later, as a result of secondary infection,
many organisms may be present.

Roentgenologic Examination—X-ray examinations in amebie infec-
tions of the lung and pleura are quite characteristic, especially those in
which perforation of a liver abseess has occurred into the lung. In the
latter instance, prior to the perforation into the thorax, liver abscess
produces a localized bulging of the diaphragm (Figs. 2 and 3). In
cases, however, in which the intrahepatic abscess has ruptured into the
subphreni¢ space with the development of a hepatie subphrenie abscess
there is elevation of the diaphragm, especially in the cardiophrenie por-
tion in the anterior posterior roentgenogram and an obliteration of the
anterior costophrenic angle in the lateral roentgenogram (Grangcer,*®
Ochsner and DeBakey‘’). In those cases in which perforation into the
lung has occurred a triangular shadow with the base toward the liver
can usually be visualized in the roentgenogram (Figs. 4 and 5). This
is particularly true in the lateral roentgcnograms, although it is also
seen in the anteroposterior roentgenogram. Our Case A 12 demonstrates
these findings especially well. Thoracic roentgenograms taken while the
patient was ambulatory showed typical localized bulging of the dia-

14
Fig. 2. Fig. 3.

 

 

 

 

 

Fig. 4. Fig. 5.

Fig. 2.—Anteroposterior roentgenogram of Case A 12 with amebic hepatitis,
showing localized upward bulging of diaphragm in its medial portion.

Fig. 3.—Lateral roentgenogram of same patient as in Fig. 2, showing triangular
shadow in lower portion of thorax with base below and apex pointing upward and
posteriorly.

Fig. 4.—-Anteroposterior roentgenogram of Case A 12 (shown in Fig. 2) taken
several hours after perforation of amebic hepatic abscess into the lung and bronchus.
In contrast to the shadow in Fig. 2, the edges of which are sharply defined, the
shadow at the right base in this roentgenogram is less distinct, particularly in the
upper portion.

Fig. 5.—Lateral roentgenogram of Case A 12 (shown in Fig. 3) taken several
hours after perforation of amebic hepatic abscess. The shadow at the right base has
extended upward and in contrast to the shadow in Fig. 3 the edges are less distinct,
especially in its uppermost portion.

15
phragm into the lower lung field (Figs. 2 and 3). Hospitalization was
advised, but was deferred by the patient for two weeks. On the day of
admission the patient experienced a severe pain at the base of the right
thorax and began to expectorate large quantities of chocolate sauce mate-
rial. Roentgenograms taken approximately three hours after the onset
of these symptoms showed extension, especially upward, of the previ-
ously demonstrated amebic hepatic abscess and irregularity of the apex
of the shadow which on previous examination was sharply defined
(Figs. 4.and 5). In cases with hematogenous lung abscess the shadow
may be located in any part of the lung, and usually there is a clear
zone between the shadow produced by the abscess and that produced by
the liver. Flynn and Warren* believe the following are cardinal roent-
genographie signs of bronchohepatic fistulas: (1) high fixed right dia-
phragm; (2) abscess mass near the diaphragm and involving the liver;
(3) column of fluid extending from this to the trachea; and (4) expec-
toration of bile-stained sputum. In the collected series of eases rela-
tively few x-ray pictures were made. In 19 of the group there was a
shadow at the right base; in 10 the right diaphragm was elevated; in 6
there was evidence of abscess in portions of the lung other than the
base, and in 1 there was evidence of fistula between the liver and the
lung. In our series of 15 cases a shadow at the right base was found in
12, there was elevation of the diaphragm in 11, abscess of the lung in
3, and abscess with fistula in 2. In these last 2 cases the fistula was
demonstrated by means of lipiodol filling.

Diagnosis—The diagnosis of amebic infections of the pleura and lung
are usually not difficult if the condition is only kept in mind. Gen-
erally, there is a history of previous diarrhea, moderate elevation of the
temperature, and enlargement and tenderness of the liver. When these
symptoms and signs are associated with pulmonary manifestations, one
should suspect an amebie infection of the lung. If, in addition to this,
there are elevation and fixation of the diaphragm and a basal shadow
on the right side together with expectoration of large quantities of ehoco-
late sauce pus, one is justified in making a positive diagnosis. We have
found, as suggested by Pellé and Baron™ and Lemierre and Bernard,* 4°
that the well-defined edge of the roentgenographie shadow is of diag-
nostic value (Figs. 4 and 5). Cannayd and Cola*? emphasize the advan-
tage of using contrast substances introduced into the bronchial tree per-
orally to visualize the communications from the liver, pulmonary ab-
scesses, and the bronchi. In 2 of our eases the fistulous communication
between the hepatic abscess and the bronchi was demonstrated by
lipiodol filling of the tracheobronchial tree. Cannavd and Cola®? also
advocate the use of pneumoperitoneum and pneumothorax as diagnostic
procedures. The finding of amebas in the sputum together with rela-
tively few microorganisms is conclusive proof of the correct diagnosis.

16
The demonstration of a clear zone between the pulmonary shadow and
that produced by the liver is indicative of a hematogenous abscess. In
those cases in which a communication between the amebie process and
a bronehus has not been established, as in empyema resulting from per-
foration of an hepatic abscess, aspiration of the fluid is a valuable diag-
nostic procedure. The finding of characteristic sterile chocolate sauce
pus, especially if it contains amebas, is pathognomonic. Amebas, how-
ever, are found infrequently in the aspirated material. In the collected
series they were found in 11 of the cases (Graph 6). In our 15 eases
the aspirated material was examined for amebas in 5, in 4 (80 per cent)
of which negative results were obtaied. In only 1 (Case A 4) were
amebas in the aspirated material.

Amebie infections of the lung are likely to be confused with tuber-
culosis, primarily because of the chronicity of the condition and because
of the profuse expectoration of bloody sputum. The physical findings
of consolidation and cavitation support this diagnosis. In tuberculosis,
however, the greatest amount of involvement is usually at the apex;
whereas in amebiasis the lesion is generally at the base and associated
with hepatic involvement. Tuberculosis can easily be eliminated as a
diagnostic possibility by the absence of tubercle bacilli in the sputum.
Some cases, because of the acute onset, are confused with pleurisy,
and pneumonia. Jt is exceptional, however, that the high leuco-
cyte count seen in the pyogenic pneumonias occurs in cases of amebic
pneumonitis; and, when such does occur, it is usually indicative of
secondary infection with pyogenic bacteria. Then, too, as a rule, the
amount of material expeetorated in cases of amebie infections of the
lung is considerably greater than that expectorated in pyogenie infee-
tions. The temperature reaction in amebie infections is considerably
lower than that in the usual pyogenic infections. Characteristically the
fever in amebic pneumonitis is only moderately elevated, and the patient,
although eacheetic, usually is not so ill as the patient with a pneumonie
process. The presence of characteristic chocolate sauce pus in the sputum
is diagnostic of amebic hepatic suppuration communicating with a
bronchus and is of value in distinguishing such lesions from other pul-
monary processes. Rarely the sputum is bile stained. In suspected
pleuropulmonary complications of amebie hepatic abscess, aspiration of
the hepatic abscess is justified. This should be done, as emphasized in
our previous communications,® *” in such a way that an uninvolved por-
tion of a serous cavity is not traversed by the aspirating needle in order
to prevent contamination of the respective cavity.

Prognosis —The prognosis in amebie infections of the pleura and lung
depends upon a number of different factors. Hussenet®? and Valence*
state that the prognosis in amebic pulmonary suppuration is dependent
upon the presence or absence of bile in the sputum. When bile is present,

17
8I

RESULTS IN

Tasue IT

COLLECTED SERIES

 

TYPE OF
THERAPY

Operation

Operation and

emetine

Emetine

No statement

made or insuffi-
cient data

Postural drain-

age

Total

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

: HEMATOGENOUS BRONCHOHEPATIC
HEMATOGENOUS PUL- PULMONARY AB- PULMONARY ABSCESS EX- FISTULA WITH EMPYEMA EX-
MONARY ABSCESS SCESS AND INDE- TENDING FROM LIVER LITTLE TENDING FROM TOTAL
parser LIVER IN- PENDENT LIVER ABSCESS PULMONARY LIVER ABSCESS
VOLVEMENT ABSCESS INVOLVEMENT
RE- RECOV- RECOV:
RECOVERED DIED | goyERED DIED RECOVERED DIED RECOVERED | DIED | prep DIED ERED | DIED
63 43, 45, 29, 30, 40, 46, 47, 49, 55, 19, 28, 44, 36, 37) 22, |14, 17, 51, 29 27
57, 58, 41, 42, 52) 56, 64, 65) 68, 70, 73, 76, | 74, 89
59, 77,| 538, 54, 61, 69, 82, 86, 75, 128 97
106 62, 66, 67,| 96, 98, 100
81, 83, 92,
95, 99
117 150 151, 152|87, 127, 1387, 85, 108, 182 107 10 2
146
109, 110, 118, 111, 112) 128 /84, 128, 134, 130 79, 80, 126, 105 35 2
114, 115, 116, 139, 140, 131, 147,
118, 119, 122, 142 148, 149
129, 133, 135,
136, 138, 141,
143, 144, 145,
153
48 60, 88, |20, 88, 39, 94)6, 9, 12, 18,16, 25, 26, | 15 00 |1, 2,3, 4,5, 15 | 32
121 120 21, 23, 24) 27, 32, 35, 7, 8, 10,
S51, 54, 50) 388, 71, 72 11, 18, 91,
93 101, 102,
103, 104,
_ 124
78 1
21 1 3 13 Be 25 27 3 6 2) 90 63
22 16 58 30 27 1538

 

 
the prognosis is much worse than when it is absent. The type of pleuro-
pulmonary involvement is important as regards prognosis, the prognosis
being gravest in those eases in which an hepatie abscess ruptures into
the pleural cavity and best in those cases in which there is a direct com-
munication between the hepatic abscess and a large bronehus with a
minimal amount of pulmonary reaction. Aecording to Thompson* the
chances of spontaneous cure are fairly good in those cases with a com-
munication between the liver abscess and the bronchus without involve-
ment of the pleura; whereas, if the pleural cavity is involved, there is
little chance of spontaneous eure. The prognosis is dependent not only

MORTALITY IN COLLECTED CASES
ACCORDING TO LESION

WM LIVER ABSCESS AND
HEMATOGENOUS LUNG ABSCESS

FJ Liver ABSCESS WITH EMPYEMA

BSS LIVER ABSCESS WITH
LUNG EXTENSION

BRONCHOHEPATIC FISTULA
(1) HEMATOGENOUS LUNG ABSCESS

 

Graph 7.—Graph showing mortality in collected cases in pleuropulmonary amebiasis
according to type of lesion.

upon the type of the pleuropulmonary involvement but also upon the
type of therapy. According to Miginiac,®*> one must differentiate between
acute and chronic amebic pulmonary abscesses. In the former there is
usually a large communication between the hepatic abscess and the bron-
chus, permitting rapid evacuation of the hepatic abscess contents;
whereas in the latter the communication is small, not infrequently there
are multiple abscesses, and as a result of the incomplete evacuation, hy-
perpyrexia, cachexia, anemia, and weakness persist. The prognosis in this
type of case is bad. The importance of adequate drainage through the
bronchus in cases of pleuropulmonary amebiasis is shown by the results

‘

19
obtained in the collected cases. Of the 30 patients with liver abscess
and bronchohepatie fistula with little or no involvement of the lung
parenchyma, 27 recovered (90 per cent) (Table II, Graph 7). In con-
trast to the high incidence of recoveries in this group of cases is the low
incidence of recoveries in those cases in which a liver abscess was compli-
cated by an empyema. In the collected series there were 27 cases with
only 6 recoveries (22.2 per cent) (Table II, Graph 7). The importance
of the use of amebicides as regards the prognosis in amebie infections of
the pleura and lung is illustrated by the results obtained in the collected
cases; 91.9 per cent of the patients receiving emctine recovered as con-
trasted with 43.9 per cent recovery in those patients not recelving eme-
tine. In our cases similar results were obtained in that there was a 40
per cent recovery in the patients not receiving emetine and 100 per cent
recovery in those cases in which emetine was used (Graph 8). The effect

INCIDENCE OF RECOVERY

WITHOUT EME TINE

WITH EMETINE

 

COLLECTED CASES AUTHORS’ CASES

series fn chowe patios Tackett tad aioe emetinen He Sar esesmes My Soe
in the treatment is graphically illustrated.

of emetine administration on the prognosis is further illustrated by the
results in the collected cases, In the cases treated by open drainage with-
out amebicides the mortality rate was 48.2 per cent; whereas in those
cases treated by open drainage and emetine the mortality rate dropped
to 15.3 per cent, and only 5.5 per cent of the patients treated by emetine
alone died (Graph 9). Theoretically the prognosis in hematogenous pul-
monary abseess should be much worse than in those eases in which there
is direct extension into the lung from the liver, because in the former
the amebas are circulating in the blood stream. In the collected series
of hematogenous lung abscess occurring concomitantly with liver sup-
puration there were 16 cases with 13 deaths, a mortality rate of 81.2 per
cent. In the group of eases, however, in which a hematogenous abscess
of the lung occurred without any involvement of the liver, there were 22

20
cases with 1 death, a mortality rate of 4.5 per cent. The great discrepancy
in the results obtained in these two groups, both with amebie blood stream
infections, is due to two factors: (1) patients with hematogenous lung
abscess and concomitant liver abscess have two suppurative processes,
either one of which is a burden for the organism to carry; (2) the type
of therapy employed in each. We believe the latter factor to be the more
important of the two. A large number in the group with the hematogen-
ous lung abscess alone received emetine; whereas relatively few of those
with concomitant liver abscess received emetine. In the former group of
22 cases all but 2 patients received emetine, and the only fatal case did
not. In the latter group of 16 cases only 6 received emetine.
Treatment—Before the suggestion of Sir Leonard Rogers,*® in 1912,
that emetine be employed in the treatment of amebie dysentery and

 

MORTALITY IN COLLECTED CASES

+ ACCORDING TO TYPE OF THERAPY

 

 

 

INSUFFICIENT OPEN OPERATION EMETINE TOTAL,
DATA DRAINAGE + EMETINE ALONE, MORTALITY

Graph 9.—Graph showing mortality in the collected series according to type of
therapy.

amebic hepatitis the results obtained in the treatment of these conditions
were unsatisfactory, Whereas at the present time there are many amebi-
cides which are morc efficacious and much safer in the treatment of
amebie lesions in the bowel; emetine still remains the sheet anchor in the
treatment of amebie infections of the liver and lung. As mentioned in
our previous publication,®? Leake” is of the opinion that although other
amebicides (acetarsone, carbasone, trepasol, chinophon, and vioform) are
safer and more efficient in the treatment of intestinal amebiasis, they
should not be used in amebic hepatic infections, because they themselves
are toxic to the liver. After the treatment with emetine and the sub-
sidence of hepatic and pleuropulmonary manifestations, however, the
underlying intestinal amebiasis is most safely and efficiently treated by
one of the above mentioned amebicides. Manson-Bahr** has emphasized

21
that emetine is more efficacious in the treatment of pleuropulmonary
amebiasis than in the intestinal lesion. The value of emetine in the treat-

Fig. 6.—Temperature chart of Case A 12, showing septic type of fever and definitive response to emetine therapy.

 

ment of pleuropulmonary amebiasis is illustrated by the results obtained
in the collected cases and in our cases (Figs. 6 and 7). In the former
group there was a recovery incidence of 43.9 per cent in patients not re-

22
ceiving emetine as compared with 91.8 per cent in those who received
emetine. In the Jatter group, the authors’ cases, the recovery incidence
in the group not receiving emetine was 40 per cent as compared with
100 per cent in those patients who received emetine (Graph 8). Simi-
larly in the collected series the effect of the administration of emetine is
illustrated by the comparison of results obtained in those cases in which

pyrexia and dramatic

irregular

showing moderate

response to emetine therapy.

7.—Temperature chart of Case A 13,

 

Fig.

open operation and drainage of the abscess was done with those in whieh
the abscess was drained together with administration of emetine. In the
former group the mortality rate was 48.2 per cent, whereas in the latter
group it was 15.3 per cent, and in a third group of cases in which emetine
alone was used, the mortality rate was 5.5 per cent (Graph 9). As sug-
gested in our previous publications® 47 on amebie hepatic suppuration
and as a result of our personal experience in pleuropulmonary complica-
tions of this condition, we are of the opinion that emetine should be

23
administered in grain doses daily until 6 to 10 grains (0.39 to 0.65 gm.)
have been given. According to Leake®® the amount of emetine adminis-
tered over any given period of time should not exceed 10 milligrams
(4% gr.) per kilogram of body weight. A maximum dose for a person
weighing one hundred and fifty pounds would be approximately 10
grains, Emetine should be used cautiously, because as shown by Rhine-
hart and Anderson,® working in Leake’s laboratory, it produces in the
experimental animal severe injury to the cardiae muscle. Similarly, as
in uncomplicated amebie abscess of the liver, external open drainage is
undesirable in nonsecondarily infected amebie infections of the pleura

 

INCIDENCE OF RECOVERIES

100 + IN
AUTHORS’ SERIES

    
  
 

ACCORDING TO
THERAPY

  

75+

504

257

 

 

CONSERVATIVE OPERATION

GrAPh Me TthOne’ series, aecording to operative and PSD eS Ty, cmmebiasis in
and lung. Although theoretically the possibility of secondary infection
of a hepatic abscess as a result of communication with a bronchus is
possible, the danger of such a complication occurring if prompt therapy
is instituted is relatively slight as evidenced by the results obtained by
conservative therapy. In the collected cases the mortality rate was much
higher when open drainage was used (48.2 per cent) than it was when
emetine alone was used (5.5 per cent). When open drainage was com-
bined with emetine therapy, the mortality rate was 15.3 per cent. The
undesirability of operating upon patients with pleuropulmonary ame-
biasis is illustrated by the results obtained in our eases in which a 33.3

24
per cent recovery incidence was obtained in the group which was operated
upon as contrasted with 100 per cent recovery incidence in the group
which was treated conservatively with amebicides (Graph 10).

The necessity of evacuating an hepatic abscess or a pleural effusion
resulting from the rupture of an hepatic abscess into the pleural eavity
cannot he overemphasized. In those cases, however, in which there is a
free communication between the hepatic abscess and a large bronchus,
evacuation of the contents of the abscess usually occurs spontaneously.
If the evacuation is incomplete, however, it is essential that the hepatic
abseess be treated as an uncomplicated one, viz., by aspiration combined
with emetine administration. Similarly in those cases in which perfora-
tion of the hepatic abscess into the pleural cavity has oecurred, aspira-
tion without open drainage should be done unless complicated by second-
ary inteetion. Similarly, as we® 47 have previously suggested in the
treatment of amebic abscess of the liver an immediate smear of the
pus should be made at the time of aspiration to determine the presence of
microorganisms. If bacteria are found, especially if there is leucocytosis
and hyperpyrexia, external drainage of the pus should be done because
of the secondary infection; otherwise, aspiration alone should be done.
Pellé*! advocates the use of pneumothorax as an aid in preventing or
controlling hemorrhage. This procedure may be an especially valuable
adjuvant in those cases in which there is a large cavity and in which
collapse is desirable, but the procedure ean be used in relatively few
eases because of the pleural adhesions which are usually present. Pellé*
also suggests postural and bronchoseopic drainage. Thompson®? advo-
cated immediate operation in those instanees in which the abseess failed
to drain through the bronehus and in cases in which the pleural cavity
was involved. Ile advised evacuation of the lung and liver abscess at
the same time the pleural cavity was drained. Vergoz and Hermenjat-
jerin®® advoeate open drainage in those cases and immediate examination
to determine whether microorganisms are present or not. If none are
present, they advocate primary closure of the wound; otherwise, open
drainage. We believe that the open evacuation of the abseess contents
is not only unnecessary but also undesirable because of the greater dan-
ger of contamination. We cannot agree with Miginiac®’ that operation
should be done in all cases of amebic abscess of the lung or empyema.
As mentioned above, although the possibility of the contamination of the
liver abscess through a hepatobronchial fistula is possible, apparently
this rarely occurs, as evidenced by the statistics obtained in our collected
and personal cases. We agree heartily with Craig? that many, if not
most, cases of amebic infections of the lung will respond to emetine ther-
apy alone and that relatively few will require surgical intervention. In
the majority of the latter, simple aspiration of the originating focus in
the liver will suffice.
Results—In the present investigation in which 1538 collected cases of
pleuropulmonary amebiasis were analyzed, the cases were divided into
five different groups according to the type of pleuropulmonary amebic
infection :

1. Hematogenous Pulmonary Abscess Without Liver Involvement.
There were 22 cases in this group, of which only 1 (4.5 per cent) died
(Table II, Graph 7). Although it would seem that the mortality rate
should be high in this group, because in hematogenous pulmonary abscess
amebas must be circulating in the blood stream, the low mortality rate
obtained was undoubtedly due to the fact that all except 2 patients re-
ceived emetine. One of those not receiving emetine was the fatal case
mentioned above and another was a patient operated upon, but who re-
covered. One other patient was operated upon, but received emetine. In
our series of cases there were no hematogenous pulmonary abscesses.
The importance of emetine administration is well illustrated in this
group, because even though a blood-borne infection or an amebiemia
must be accepted, the mortality rate of 4.5 per cent is exceptionally low,
undoubtedly due to the high incidence of emetine administration.

2. Hematogenous Pulmonary Abscess and Independent Liver Abscess.
—There were 16 cases of hematogenous lung abscess occurring concom-
itantly with a liver abscess, the two, however, being unassociated
(Table II, Graph 7). In the 16 cases there were 13 deaths (81.2 per
eent mortality). Of the 13 fatal cases, 9 patients were operated upon,
only 2 of whom received emetine. Three of the other 4 fatal eases had
no therapy; one, however, received emetine. Three patients recovered, all
of whom received emetine and 1 of whom was operated upon. Of the
entire 16 cases, only 6 patients received emetine, 3 of whom recovered
and 3 died. One of the former was operated upon; whereas 2 of the
fatal eases were also operated upon. The high mortality rate in this group
(81.2 per cent) as contrasted with the low mortality rate (4.5 per cent)
in those cases of hematogenous lung abscess not associated with liver
abscess is probably due to two factors. Even though in both groups of
cases an amebiemia was present, in those cases in which there was a con-
comitant liver involvement the patient was undoubtedly more toxie be-
cause of the additional focus. The more important reason, to our minds,
is the fact that relatively few, less than a third of the patients, in whom
a liver abscess and hematogenous lung abscess occurred concomitantly
received emetine as contrasted with 90 per cent of those patients in whom
a hematogenous lung abscess alone was present. In our series of cases
there were none in this group.

3. Pulmonary Abscess Extending From a Liver Abscess—This com-
prised the largest group of the collected series. There were 58 cases, 25
of which (48.2 per cent) were fatal (Table II, Graph 7). Of the 25 fatal
cases, 13 were operated upon. In 11 no therapy was used or the details

26
were incomplete and 1 received emetine alone. Of the 33 patients who
recovered, 21 were operated upon, 4 of whom received emetine, The 6
additional patients who recovered received emetine alone. In 5 no state-
ment was made eoneerning the therapy. In 1 postural drainage alone
was used. Of the 11 patients who received emetine only, 10 recovered
and only 1 died. Of the 58 eases there were only 42 in which details were
given as regards therapy. Of these, 11 reecived emetine with 90.9 per
eent recoveries. Of the 31 patients not receiving emetine, 13 died and
18 recovered (58 per cent). Of 34 patients operated upon, 13 died and
21 recovered (61.7 per cent). The effect of the administration of emetine
is well illustrated by these cases, a 90 per cent recovery incidence in those
eases in which emetine was given as contrasted with 58 per cent incidence

TasBLe IIT

RESULTS IN AUTHORS’ SERIES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BRONCiL0-
PULMONARY HEPATIC EMPYEMA
ABSCESS FISTULA WITH EXTENDING
TYPE OF EXTENDING LITTLE FROM LIVER TOTAL
THERAPY FROM LIVER PULMONARY ABSCESS
ABSCESS INVOLVEMENT
RE- RE- RE- RE-
coveRED | PIED | coverrp | PIFP | covenep | PIED | covennmn | PEEP
Operation Al5 AT 1 1
Operation and A8 1
amebicides
Emetine or other} A 2, A 4, A3, Al 10
amebicides Ad, AG, All,
A13, Al2
Al4
No statement AQ A 10 1 1
made or in-
sufficient data
6 3 3 2 12 3
Total _ 1 . — _—
7 3 3 15

 

 

 

 

 

in the group in which emctine was not given. The value of conservative
therapy is also illustrated by the results obtained in our cases of pulmo-
nary amebic abscess secondary to liver abscess rupture. Seven patients
were of this type, 6 of whom received amebicides, all of whom recovered
(Table III). Only 1 who had no treatment died.

4. Bronchohepatic Fistula With Little Pulmonary Involvement —In
the collected cases there were 30 patients with liver abscess and broncho-
hepatic fistula in whom the liver abscess evacuated through the bronchus
with a minimal amount of pulmonary reaction (Table IT, Graph 7). Of
the 30, 27 recovered (90 per cent) and 3 (10 per cent) died. Two of the
3 fatal cases were operated upon. In 10 of the 30 cases insufficient data
concerning the type of therapy were given. Emetine was administered
to 10 of the 27 patients who recovered. Three of these were also operated

27
upon. All the patients receiving emetine recovered. Two of the 13 pa-
tients operated upon died, neither of whom had received emetine. Thus
it is seen that half of the eases in which sufficient data are available re-
ceived emetine, and all of these patients recovered. The only death in
the series occurred in that group of patients who were operated upon
and who did not receive emetine. There were 3 patients of this type in
our series, all of whom recovered following the conservative treatment
with amebicides (Fig. 8). It is obvious that bronehohepatie fistula with
complicating amebie liver abscess with adequate evacuation of the abscess
through the bronchus offers a relatively good prognosis and especially if
emetine is administered.

 

 

 

 

 

Fig. 8.—-Anteroposterior roentgenogram of Case A 12 (shown in Figs. 2, 3, 4, 5).
This plate was made approximately six weeks after those shown in Figs. 4 and 5,
showing almost complete disappearance of shadow at base of right lung. The patient
was symptom free at the time this roentgenogram was taken.

dD. Empyema Extending From Amebic Liver Abscess.—In the series of
collected cases there were 27 with liver abscess in which the abscess rup-
tured into the pleural cavity with the development of an empyema. In
this group there were 21 deaths (77.7 per cent) (Table II, Graph 7).
In 16 of the 21 fatal cases no details concerning therapy were given. Ten
of these were observed early, before 1900. The other 5 fatal cases were
operated upon. Of the 6 patients who recovered, 4 were operated upon,
1 of whom received emetine and 1 not operated upon also received eme-
tine. Only 2 reecived emetine, both of whom recovered. In our series
(Table IIT) there were 5 with empyema complicating amcbie hepatic
abseess. In 1 the pleural cavity alone was involved (Case A 7) and in

28
4 the pleural cavity and lung were involved concomitantly. Two (40
per cent) of the 5 patients died. Three (60 per cent) of the 5 were
operated upon, 2 of whom died. Only 1 of the 5 patients received amebi-
cides; he also was operated upon and died. These figures would indicate
that the prognosis in empyema extending from amebic liver abscess is
grave. On the other hand, the high mortality rates obtained in the
collected series (77.7 per cent) and in our series (40 per cent) are prob-
ably due to the fact that emetine was used in few instances (20 per eent
in both the collected and our series) and that open drainage was fre-
quently employed (90 per cent in the collected cases and 60 per cent in
our series). It is our prediction that had open operation been used less
frequently and emctine administcred more frequently, the mortality rates
would have been much lower, It is important, however, that in these
cases evacuation of the pleural contents be accomplished by aspiration in
the noninfected cases and by some type of drainage in those cases which
are secondarily infected.

The results obtained by the various methods of treatment in pleuro-
pulmonary complications of amebiasis vary considerably (Table II,
Graph 9). Of the 153 collected cases, 63 patients died (41.1 per cent).
Of the entire group there were 47 eases in which insufficient data were
given or in which nothing was done and in which no conclusions can be
drawn coneerning the results obtained by various therapeutic measures,
of which 32 patients (68 per cent) died. Fifty-six patients were treated
by open drainage alone, of which 27 (48.2 per cent) died. Twelve pa-
tients were treated by open operation and emetine, of whom 2 died (16.6
per cent), Thirty-seven patients were treated by emetine alone, of whom
2 (5.4 per cent) died. Of the entire group of 153 eases, 49 patients re-
ceived emetine with only 4 deaths (8.1 per eent); whereas 59 of the
remaining 104 died (56.7 per cent). The results obtained in these cases
demonstrate that operation offers relatively little in the treatment of
pleuropulmonary amebiasis. The mortality rate in this group is ex-
tremely high (48.2 per cent), but ean be definitively deercased (16.6 per
cent) by the administration of emetine. The best results, however (5.4
per eent mortality), were obtained in those patients who were not op-
erated upon, but in whom emetine alone was used. In our 15 eases, 3
patients died (20 per cent). Of the 15 eases only 14 patients were
treated, 1 dying before treatment could be instituted. Of these 14, 3
were operated upon, 2 (66.6 per cent) of whom died. Of the remain-
ing 11 treated conservatively, none died (Graph 10). In our series
there were 6 patients who reccived emetine alone or in combination with
other amebicides; all of whom recovered. Seven received amebicides
other than emetine, with one death. Two received no amebicides, both
of whom died. As mentioned under treatment, we are of the opinion
that emetine is the specific drug in the treatment of pleuropulmonary
amebiasis.
SUMMARY AND CONCLUSIONS

1. An analysis of 153 collected and 15 of our own eases of pleuropul-
monary amebiasis is presented.

2. Pleuropulmonary complications of amebiasis occur much more fre-
quently than is generally supposed. They occurred in 15.8 per cent of
2,490 reported and in 15.7 per cent of our 95 consecutive eases of
amebic hepatic abscess.

3. The greatest number of patients in the collected series (38 per
cent) were in the third decade of life; whereas the greatest number in
our series (40 per cent) were in the fifth decade of life.

4, Males are involved much more frequently than females (96.2 per
cent in the collected and 93.3 per cent in our series). In our series 9
patients were white and 6 colored.

5. Pleuropulmonary complications of amebiasis oceur, as a rule, re-
sulting from an extension of amebie hepatic abscess. Perforation of
the absecss rarely occurs into the free pleural space, but more frequently
into the lung or bronchus. Exceptionally hematogenous pulmonary
amebic abscesses may occur,

6. Pleuropulmonary amebic infections are classified into five groups,
depending upon the type of pleuropulmonary involvement: (1) hematog-
enous pulmonary abscess without liver involvement; (2) hematogenous
pulmonary abscess and independent liver abscess; (3) pulmonary ab-
scess extending from liver abscess; (4) bronehohepatie fistula with lit-
tle pulmonary involvement; (5) empyema extending from liver abscess.
In 14.3 per cent of the collected series the pleuropulmonary lesion was a
hematogenous pulmonary abscess without liver involvement. In 10.4
per cent the lesion was a hematogenous pulmonary abscess together with
an independent liver abscess. In 37.2 per ecnt the lesion was a pul-
monary abscess extending from a liver abscess. In 19.6 per cent the
lesion was a bronchohepatic fistula with little pulmonary involvement,
and in 17.6 per cent the lesion was an empyema extending from a liver
abscess. Pulmonary abscess extending from a liver abscess comprised
46.6 per cent of our 15 cases, bronchohepatic fistula with little pul-
monary involvement, 20 per cent, and empyema extending from a liver
abscess, 33.3 per cent.

7. The clinical manifestations of pleuropulmonary amebiasis consist
chiefly of cough and expectoration, fever, diarrhea, enlarged and tender
liver, pain in the chest, and cachexia. Cough and expectoration were
observed in 92.5 per cent of the collected cases, fever in 43.2 per cent,
a history of a previous diarrhea was obtained in 41 per cent, an en-
larged liver present in 39.7 per cent, diarrhea at the time of admission
in 33.5 per cent, and pain in the chest in 31.3 per cent. The expectora-
tion of chocolate sauce pus is indicative of a communication between a

30
liver abscess and a bronehus and is of diagnostic importance. Pul-
monary manifestations consist of consolidation and cavitation.

8. There is characteristically a moderate leucocytosis without con-
comitant increase in the polymorphonuclear leucocytes. A marked leuco-
cytosis is indicative of a secondary infection.

9. X-ray examination shows elevation and fixation of the diaphragm
and a shadow at the right base, particularly in those cases in which a
pulmonary abseess extends from a liver abscess. Characteristically the
shadow is triangular with the base below and the apex above.

10. Diagnosis can be definitively established by the characteristic
chocolate sauce pus and the finding of amebas in the sputum and aspi-
rated material.

11. The prognosis in pleuropulmonary amebiasis is dependent upon
the type of the lesion and the therapy employed. The mortality rate
in the collected series was extremely high (41.1 per cent). In the group
with liver abseess and hematogenous lung abscess the mortality rate was
81.2 per eent. In the cases of liver abscess with empyema it was 77.7
per eent. In eases of lung abscess extending from liver abscess it was
43.2 per cent. In eases of bronehohepatic fistula with a minimal amount
of pulmonary involvement it was 10 per cent. In the cases of hematog-
enous lung abscess without liver abscess it was 4.5 per cent. The prog-
nosis depends probably more upon the type of therapy than upon the
type of lesion. The mortality rate obtained in the eases treated by open
drainage was 48.2 per cent, that in the cases treated by open drainage
and emetine, 16.6 per cent, whereas that obtained by emetine alone was
o.4 per cent.

12. The treatment of pleuropulmonary amebiasis consists of the ad-
ministration of emetine and the aspiration of those abscesses not suffi-
ciently evacuated through the bronchus. Open drainage should never
be done except in those cases with secondary infection. The importance
of emetine in the treatment of amebie pleural pulmonary complications
is illustrated by the results obtained in the collected and in our eases.
The incidence of recovery in cases treated without emetine in the col-
lected cases was 43.9 per cent and in our cases 40 per cent; whereas in
those cases receiving emetine the respective incidences were 91.8 per eent
and 100 per cent,

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30