A 75-year-old Caucasian builder with a known case of ulcerative colitis presented to the Southmead Hospital Emergency Department with a history of pyrexia associated with urinary symptoms. Three weeks prior to presentation, he had developed coryza, rigors and aching shoulders associated with pyrexia. He was seen by his GP who initially treated him for a suspected community-acquired pneumonia with amoxicillin. Seven days prior to admission, he returned to his GP with an ongoing history of intermittent pyrexia. He was treated for a urinary tract infection with a course of trimethoprim for 5 days. Despite this, he continued to deteriorate and developed progressively reduced mobility and muscle weakness. He was again treated with another course of antibiotics by his GP; however, he had deteriorated so much at this point that he was "unable to hold anything down," and it was then when he decided to go to hospital as he started vomiting. On admission, he was short of breath accompanied by wheezing. There was no cough or hemoptysis. There was no change in bowel habit, no history of foreign travel, weight loss, night sweats nor any recent history of unusual food substances. Interestingly, he mentioned that he had had occasional bouts of lower abdominal pain, which was "normal" for him. He had a past medical history of asthma, hypertension, non-ST elevation myocardial infarction, benign prostatic hypertrophy and ulcerative colitis. He lived with his wife in a house with stairs. He experienced one fall recently associated with a temperature spike. He was an ex-smoker (8-10 cigarettes per day for 55 years) and was an active builder. On physical examination, he was pyrexial with a temperature of 37.1 C and normotensive with a blood pressure of 107/62 mm Hg. Pulse was 62 bpm, and respiratory rate was 25 breaths per minute saturating at 99% SpO2. Cardiovascular examination revealed normal heart sounds accompanied by a soft systolic murmur. Upper airway wheeze was heard but not on auscultation as the lungs were otherwise clear. Abdomen was soft and non-tender with a small reducible umbilical hernia. Bowel sounds were present and normal. He was grossly moving his 4 limbs with ease. Investigations on admission revealed a white blood cell count of 14.54 x 109/L, haemoglobin of 80 g/L, mean corpuscular volume of 79.6 fL, mean corpuscular haemoglobin of 25.6 pg, neutrophils of 12.49 x 109/L, C-reactive protein of 203 mg/L and estimated glomerular filtration rate of 52 mL/min. Interestingly, his liver function tests demonstrated a bilirubin of 11 mumol/L, alkaline phosphatase of 195 U/L, alanine transaminase of 36 U/L and albumin of 26 g/L. His chest X-ray revealed a suspicious 8-mm nodule within the left apex, no focal consolidation and clear pleural spaces with right apical pleural thickening (Fig. 1). Urinalysis was negative and electrocardiogram showed normal sinus rhythm. Venous blood gas was unremarkable. At first, the patient was presumed to have an infection from unknown origin accompanied with anaemia either secondary to iron deficiency anaemia or due to an underlying malignancy. The patient was commenced on empiric intravenous co-trimoxazole and gentamicin. Blood and urine cultures were sent to the laboratory prior to this. In view of the findings of abnormal urinary symptoms and the findings on the chest X-ray, an ultrasound of the urinary tract along with a computed tomography (CT) scan of the chest, abdomen and pelvis were obtained. An echocardiogram was performed to rule out infective endocarditis.
In the meantime, the patient was transferred to the Geriatric Ward. Despite all efforts, the patient continued to deteriorate with progressively worsening nausea and was no longer able to tolerate his oral medication. He began to develop new symptoms, including right-sided neck pain and intermittent rigors. CT scan of the chest, abdomen and pelvis was performed and showed 3 main findings: a right apical nodule, a small colonic lesion (being suspected malignancy or diverticulitis) and an irregular mass in the liver (Fig. 2a, b). Therefore, the differential diagnosis at the time was a liver abscess and colon carcinoma with metastatic deposits to the lung and liver. There was no evidence of intrahepatic or extrahepatic biliary dilatation. After discussion of these findings with the patient, he then openly admitted that he had a history of tuberculosis in his right lung as a child and was isolated at the age of 5 years for 9 months in Swansea. He recalled being told by medical personnel there that he had developed scarring ever since the treatment in his right lung. This would explain the appearance of the right apical nodule (Fig. 1). In view of the CT scan findings, an ultrasound of the liver was arranged, and if that would reveal a liver abscess, then an ultrasound-guided liver drain would be performed. Intravenous metronidazole was added to the antibiotic therapy regimen, more blood cultures were taken, and a colonoscopy was also arranged. The patient deteriorated so much that he began to lose the ability to mobilise without aid due to his progressive muscular weakness. He now complained of right upper quadrant pain accompanied by pain in his right shoulder with worsening nausea. After discussion with the microbiology team, S. intermedius was isolated as the main pathogen in his blood cultures, which was sensitive to teicoplanin. A liver ultrasound confirmed a large mixed echogenicity lesion at the superior aspect of the liver abutting the diaphragm measuring approximately 6.7 x 6 cm. Therefore, an ultrasound-guided drain was inserted in the cavity. Narrow-spectrum antibiotics, such as intravenous teicoplanin, metronidazole and gentamicin, were started. The patient expressed immediate relief following the drain insertion. Surprisingly, he was then able to tolerate food and was able to walk around the hospital freely for the first time. His colonoscopy revealed evidence of inflamed colon and areas of diverticulosis with no evidence of malignancy (Fig. 3). The diagnosis was most likely a liver abscess secondary to sigmoid diverticulitis caused by S. milleri group bacteria. The second differential diagnosis was an abscess as a complication of a resolving bout of ulcerative colitis in view of this patient's history. Otherwise, his neutrophilia began to improve significantly along with his liver function tests. A repeat CT scan of the abdomen was performed, which demonstrated significant improvement in the size of the liver abscess. The patient was discharged home to complete a 4-week course of oral antibiotics. A subsequent CT scan taken several months after discharge showed resolution of his abscess.