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Diagnostic ImagesMisdiagnosis of Liver Abscess Resulting From Misunderstood Culture Results

Misdiagnosis of Liver Abscess Resulting From Misunderstood Culture Results

Noncontrast computed tomography of the abdomen performed at the time of admission showed no significant findings (A). Abdominal contrast-enhanced computed tomography on day 12 revealed a 4-cm liver abscess (B).

 

An 83-year-old man visited the emergency department with a high-grade fever that lasted for several hours. His past medical history was remarkable for cerebral infarction, prostate cancer, diabetes mellitus, and atrial ventricular block. He was taking aspirin, clopidogrel, bicalutamide, rabeprazole, glimepiride, teneligliptin, and isosorbide sulfate. Physical examination revealed that the patient was diaphoretic but not in acute distress. His body temperature was 40.2°C, but other vital signs were normal. He was neither anemic nor icteric. Auscultation revealed that his chest was clear, and heart sounds were normal. His abdomen was soft, non-tender, and non-distended, without hepatosplenomegaly or costovertebral angle tenderness. Results of laboratory analyses revealed mild leukocytosis (leukocytes, 7790/μL with 94% neutrophils) and slight abnormalities in liver function (aspartate transaminase, 26 U/L; alanine transaminase, 106 U/L; alkaline phosphatase, 465 U/L; gamma-glutamyl transferase, 142 U/L; and total bilirubin, 1.7 mg/dL). Urinalysis revealed positive results for nitrate and high levels of white blood cells (10-19 per high-power field). Noncontrast computed tomography (CT) of the chest and abdomen revealed no remarkable findings indicating the cause of fever, other than urinary retention (Figure A).

 

The patient was diagnosed with acute pyelonephritis based on the presence of nitrate and white blood cells in the urine and was admitted to our hospital. Intravenous administration of ceftriaxone was initiated. On day 4, urine and blood cultures obtained at the time of admission were found to be positive for Pseudomonas aeruginosa and Klebsiella pneumoniae, respectively; therefore, ceftriaxone was replaced with ceftazidime. His condition and laboratory results improved promptly, and he was scheduled for discharge. However, on day 12, a visiting teaching physician indicated concern about the inconsistency between the blood and urine cultures and recommended further workup to assess other causes of bacteremia. Contrast-enhanced abdominal CT revealed a 4-cm liver abscess (FigureB). The patient was diagnosed as having a liver abscess and was treated with long-term antibiotics without drainage. The patient was completely cured following treatment.

 

 

To read this article in its entirety please visit our website.

-Kai Uehara, MDa,b, Yukinori Harada, MDa,c

This article originally appeared in the February 2020 issue of The American Journal of Medicine

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