An Atypical Presentation of Pyogenic Liver Abscesses

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Introduction: Pyogenic liver abscesses (PLA) often present with classic signs and symptoms and have a high mortality rate if not treated timely. Our patient presented with respiratory symptoms secondary to PLA following cholecystectomy 1 year ago. The patient is a 73-year-old male who presented with a 6-month history of worsening shortness of breath. He also reported a 125-pound weight loss over the past year. His symptoms began post cholecystectomy, and an abdominal computed tomography (CT) scan demonstrated multiple liver infiltrates, which were initially thought to be bilomas or bile leaks. He presented with stable vital signs, and a subsequent CT scan showed a right-sided pleural effusion with multiple abscesses in the liver, the largest being 9.1 x 4.9 cm. He was initiated on intravenous ciprofloxacin and Imipenem, as well as interventional radiology-guided drain in the largest abscess. The patient demonstrated significant clinical and radiologic improvement. PLA usually occur after portal vein pyemia, secondary to bowel leakage and peritonitis, but may also occur due to infection secondary to obstruction or penetrating wounds. PLA usually presents with right upper quadrant pain, fever, chills, and weight loss. Patients with single abscess may have an insidious course, but multiple abscesses usually present with acute symptoms. This case is unique in that our patient had an insidious presentation with uncommon clinical features, which makes early suspicion of the disease difficult. In spite of untreated multiple abscess, which carries a very high mortality, our patient was not acutely sick and did not require intensive care. A right-sided pleural effusion can be seen in some cases. These findings should prompt additional investigation such as right upper quadrant ultrasonography or CT scan. Cultures obtained from existing drains should not be used to guide antimicrobial therapy. The diagnosis of PLA is made by history, clinical examination, and radiographic imaging, along with aspiration and culture of the abscess material. Treatment of PLA should include drainage and antibiotic therapy.Figure 1