The Sweet Smell of Trouble

A 54-year-old man with no significant past medical history presents with four weeks of low-grade fever, drenching night sweats, right upper quadrant discomfort, and a 10-pound unintentional weight loss. He denies recent travel, sick contacts, alcohol use, or any recent dental or surgical procedures. He has not seen a physician in several years and is not up to date on preventive health maintenance.

On examination he is febrile to 38.9°C, heart rate 98 bpm, blood pressure 118/74 mmHg, and oxygen saturation 98% on room air. He appears fatigued and has lost muscle mass. There is tenderness to palpation in the right upper quadrant without peritoneal signs. The liver edge is palpable 3 cm below the costal margin. No splenomegaly, jaundice, or lymphadenopathy is present.

White blood cell count is 15,800/μL with 86% neutrophils and 11 bands. Hemoglobin is 10.4 g/dL (normocytic). Platelet count is 512,000/μL. ESR is 118 mm/hr and CRP is 194 mg/L. Alkaline phosphatase is 312 U/L; AST and ALT are mildly elevated. Total bilirubin is normal. Serum albumin is 2.8 g/dL. CT of the abdomen with contrast reveals an 8 cm multiloculated low-attenuation lesion in the right hepatic lobe with peripheral enhancement and internal septations, consistent with a pyogenic abscess. No pneumobilia is identified. Two sets of blood cultures are drawn before antibiotics are started.