Isolated Pyrexia: The Hunt for Disease in a Patient Without Discernible Risk Factors

Abstract

Hepatic abscesses are relatively rare and require prompt recognition and early intervention to reduce morbidity and mortality, which may be significant if left untreated. We present a case of pyogenic liver abscess with atypical presentation and absence of discernable risk factors. 59-year-old male with a history of hypertension and hyperlipidemia presented to the emergency department with complaints of daily fevers for approximately 4 days reaching a maximum temperature of 104.1°F. The fevers did not follow any particular pattern, were partially relieved by acetaminophen, and were associated with fatigue but no chills. He denied any abdominal or chest pain, dyspnea, nausea, vomiting, diarrhea, constipation, dysuria, headache, neck stiffness, rash, arthralgia, joint swelling, back pain, sore throat or any other symptom. He had no recent medication changes, history of prosthetic joint or valve replacement, or history of surgery. He underwent annual dental evaluations with no recent dental cleanings and was up to date on his screening colonoscopy with follow up in 8 years. On physical exam, his vital signs were normal except tachycardia to 113 beats per minute and a temperature of 102.9F. He was alert and in no acute distress. His physical exam was absent for any abnormality with unremarkable head, neck, cardiac, lung, abdominal, extremity and skin exam. Laboratory analysis was significant for elevated liver enzymes and a mild leukocytosis. An abdominal ultrasound showed a lobulated circumscribed heterogeneous mass suspicious for malignancy or abscess that was later confirmed on CT scan. He was found to have elevated ESR, CRP, and procalcitonin values with an undetectable alpha fetoprotein. Antibiotics were initiated and he underwent percutaneous hepatic drain placement. Blood cultures were positive for streptococcus intermedius. Dental evaluation via xray panorex and CT neck studies were negative for dental infection. Transthoracic and transesophageal echo evaluation were negative for endocarditis. He improved and discharged home with hepatic drain in place and antibiotic infusions until he showed clinical evidence of resolution of infection. This case illustrates a potentially lethal infectious process that presented in an atypical manner and without known risk factors. It emphasizes the significance of maintaining clinical suspicion for occult abscess and prompt but appropriate imaging if there are no clear foci of infections with respect to history.Figure 1Figure 2