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Rebecca Lazarus, MD*1;Michael Moses1 and Nicole M. Adler, MD, FACP, FHM2,
(1)NYU School of Medicine, New York, NY, (2)NYU Langone Medical Center, New
York, NY

Meeting: Hospital Medicine 2017

Abstract number: 550

Categories: Adult, Clinical Vignette Abstracts

Keywords: Appendicitis, Liver abscess and Sepsis

Case Presentation: A 26 year-old Singaporean man with no past medical history

presented with two weeks of fevers and abdominal pain. Five months prior to
admission, the patient traveled to Singapore. Two weeks prior to presentation, he had
an episode of sharp, right-sided abdominal pain accompanied by emesis. He continued
to have intermittent fevers, chills, headaches, abdominal pain, and weight loss. On
presentation, he was febrile to 102.9F, with heart rate of 115 beats/minute. Physical
exam was notable for mild hepatomegaly. Blood tests demonstrated AST 71, ALT 128,
alkaline phosphatase 116, total bilirubin 1.2, INR 1.5, and WBC 17.4 with 89%
neutrophils. Abdominal CT scan revealed hepatomegaly with multiple liver mass
lesions demonstrating both solid and cystic components, the largest of which measured
7.6 x 4.6 cm, as well as lobular wall thickening of the appendix. The patient was treated
with ceftriaxone 2g daily and metronidazole 500mg three times daily, and underwent
IR-guided drainage of the liver lesions and a laparoscopic appendectomy. Cultures from
the blood and abscesses remained negative, but the IR-guided drainage returned
purulent fluid and the appendix pathology revealed inflammation consistent with
subacute appendicitis with possible diverticulum versus healing abscess. Antibiotics
were continued and symptoms resolved.


We present the case of a young, healthy Singaporean man who developed pyogenic
liver abscesses (PLA) in the setting of appendicitis. Liver abscesses are most frequently
caused by biliary disease, but can be secondary to diverticulitis, appendicitis, perforated
ulcers or malignancies, and inflammatory bowel disease. PLA secondary to appendicitis
is rare, and most cases are associated with liver abscess formation following treatment
of a perforated, gangrenous, or phlegmonous appendicitis. Unique to this case is that the
appendix was only notable for a possible healing abscess; and further, that the
appendicitis and liver abscesses were diagnosed and managed concomitantly.
Historically, E. Coli has been the predominant cause of PLA, though Klebsiella
pneumoniae is emerging as the causative agent in a large proportion of liver abscess
cases in Asia, and a rapidly growing number in the United States as well. A common
risk factor for klebsiella liver abscesses is poorly controlled diabetes; other risk factors
include cholelithiasis, malignancy, and prior intra-abdominal surgery. Our patient did
not have any of these, and was younger than the majority of patients in the literature.
Klebsiella liver abscesses present with similar symptoms and lab abnormalities to other
bacterial liver abscesses, though with milder alkaline phosphatase and total bilirubin


Pyogenic liver abscesses can present in young otherwise healthy patients. It is important
to consider pyogenic liver abscess in the differential of sepsis of possible hepatobiliary
etiology, as urgent abscess drainage is often required.