Cyst in the liver and cough with copious purulent sputum

Abstract

A 40-year-old woman presented with a history of pain in the right lower chest, fever and cough with purulent sputum in the previous 20 days. She was treated for a presumed lower respiratory tract infection and her fever subsided, but she continued to produce 400-500 mL of purulent sputum daily, which was blood-tinged on two occasions. Her past medical history was unremarkable. On examination she was pale and afebrile; pulse and blood pressure were normal. Local examination of the chest with palpation and auscultation revealed reduced breath sounds in the right infrascapular region, with some crepitations. Abdominal examination found an enlarged liver. Blood investigations revealed a hemoglobin of 9 g/dL and a white blood cell count of 14×109/L with 10% eosinophils. Serum bilirubin, alkaline phosphatase and transaminase levels were normal. Chest x-ray showed an elevated right hemidiaphragm and right lower zone consolidation; no air fluid level or pleural effusion was seen. Abdominal ultrasonography revealed a right lobe liver cyst with internal echoes inside and wall calcification. The patient was further evaluated by contrast-enhanced multidetector-row CT (MDCT) on a 64-detector row CT. Transverse CT through the chest showed soft issue attenuation due to consolidation in the lower lobe of right lung involving lateral basal, medial basal and posterior basal segments with rounded and elongated fluid attenuation areas within it (Figure 1). CT images through the upper abdomen showed a cystic mass in segment VII of liver with a focus of air attenuation in it anteriorly (Figure 2). The cyst wall showed curvilinear calcification; bile ducts were not dilated.