Unusual Case of Fever and Abdominal Pain

A 63-year-old man presented to our tertiary medical center with a 2-day history of nausea, multiple episodes of nonbloody, nonbilious emesis, generalized abdominal pain, malaise, chills, and fever up to 39°C. He had no history of hepatobiliary disease or diabetes. The physical examination was notable for right-sided abdominal tenderness to deep palpation without rebound and guarding. Laboratory workup (reference range in parentheses) revealed hemoglobin 12.9 g/dL (13.5-17.5 g/dL), leukocytes 14.4 × 109/L (3.5-10.5 × 109/L), aspartate aminotransferase 266 U/L (8-48 U/L), alanine transferase 201 U/L (7-55 U/L), total bilirubin 0.9 mg/dL (≤1.2 mg/dL), direct bilirubin 0.7 mg/dL (0-0.3 mg/dL), international normalized ratio 1.3 (0.9-1.1), albumin 3.2 g/dL (3.5-5 g/dL), and lactate 2.7 mmol/L (0.6-2.3 mmol/L).

Upon admission the patient was given intravenous fluid and started on pipercillin-tazobactam. However, within a few hours he became diaphoretic, hypotensive, tachycardic, tachypneic, and was transferred to the medical intensive care unit for further care. An additional 30 cm3/kg intravenous fluid was given, and vancomycin was added to the antibiotic coverage. He remained hemodynamically stable throughout his medical intensive care unit admission and did not require pressor support.

A computed tomography scan of the abdomen/pelvis was obtained, which revealed a low attenuating lesion within the right lobe of the liver measuring 5.2 × 5.0 × 5.8 cm (Figure A), mild diffuse gallbladder wall thickening measuring 4-5 mm with pericholecystic fluid and mural edema, mild pericolonic fat stranding in the sigmoid colon (Figure B), and mild focal colonic wall thickening involving a diverticulum. An abdominal ultrasound scan revealed a 5.6-cm hyperechoic area in the central liver (Figure C), consistent with a liver abscess, and a thick-walled gallbladder filled with stones (Figure D). There was no bile duct dilatation. A sonographically guided percutaneous catheter drain was placed into the right liver abscess (Figure E), and 12 mL of purulent fluid was aspirated. The aspirated fluid and blood cultures returned positive for S. anginosus. Antibiotics were de-escalated to ceftriaxone and metronidazole, which were switched to ertapenem at the time of discharge and continued for 4 weeks from the time of percutaneous catheter drain placement. At discharge his symptoms had resolved. The percutaneous catheter drain was removed 10 days after it was inserted. An interval cholecystectomy and colonoscopy were scheduled to exclude colorectal neoplasia.