A 59-year-old White woman presented with painless jaundice, pruritus, and 10-lb weight loss over a month to an outside facility. She did not have any fever. There was no past history of pancreatitis, abdominal surgery, or trauma. She had no history of smoking. Her labs were: total bilirubin 11.0 mg/dL, direct bilirubin 10.2 mg/dL, alkaline phosphatase (ALP) 655 U/L, aspartate aminotransferase (AST) 92 U/L, and alanine aminotransferase (ALT) 96 U/L. Magnetic resonance imaging showed a 4.5-cm mass at the porta hepatis with compression of the common bile duct and portal lymphadenopathy. CA 19-9 was elevated at 96 U/ml. She underwent a placement of two external biliary drains and had resolution of the jaundice. She was presumed to have Klatskin tumor, based on her clinical and radiological presentation, and the mass was unresectable given its proximity to the portal vein and hepatic artery. She was referred to our center for medical management of cholangiocarcinoma. Patients initially choose to be palliative and refused biopsy considering the high mortality of the tumor. She presented a few days later with abdominal pain and agreed for a biopsy. A few days after a computed tomography (CT)-guided biopsy of the mass, she developed fever, chills, hematemesis, and abdominal pain. On examination, she had a temperature of 99.6°F, blood pressure of 105/60 mmHg, pulse of 105/min, and respiration of 20/min. Her lungs were clear to auscultation. She had tenderness in the right upper quadrant of the abdomen. A repeat CT scan showed a 4.7-cm porta hepatis mass with encasement of the hepatic artery and with loss of fat planes between the mass and the gall bladder and duodenum (Fig. 1). A 1.7-cm gall stone was visualized. A 1-cm gastrohepatic lymph node was seen along with scattered lymph nodes measuring up to 1 cm in the retrocaval, aortocaval, and periaortic regions. Two biliary stents were in place. Upper gastrointestinal endoscopy showed fresh blood oozing from the ampulla of Vater, which was felt to be due to her mass. Digital subtraction angiography of the celiac trunk and superior mesenteric artery showed an 8-mm pseudoaneurysm of the third segmental branch of the left hepatic artery (Fig. 2). The bleeding was successfully stopped with coil and gel foam embolization. The pathology of the bile duct mass was negative for malignancy but showed acute and chronic inflammation and granulomas with gram-positive filamentous bacteria consistent with actinomycetes species (Fig. 3). Cultures grew Streptococcus constellatus, Prevotella intermedia, and Prevotella oris. The patient was started on IV penicillin, oral metronidazole and levaquin while in the hospital and made a slow recovery. M. Bansal (*) :A. Agarwal Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205, USA e-mail: mbansal@uams.edu