Images in Clinical Medicine

Liver Abscess with Septic Pulmonary Emboli

Herbert L. Fred, M.D., and Shehzad Basaria, M.D.

N Engl J Med 1997; 336:1428May 15, 1997

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Figure 1 A previously healthy 52-year-old man presented with right-sided pleurisy, fever, and shaking chills for three days. On examination he was febrile and had marked tenderness to percussion over the right lower rib cage. A chest radiograph showed an elevated right hemidiaphragm and several lesions characteristic of septic pulmonary emboli in the left lower lobe (Panel A, arrows). Abdominal ultrasonography demonstrated a large, complex, predominantly hypoechoic mass in the posterior segment of the right hepatic lobe (Panel B, arrows). Contrast-enhanced abdominal computed tomography showed involvement of both the hepatic parenchyma (Panel C, arrows) and the right hepatic vein (Panel D, arrows). A transthoracic echocardiogram was normal. Aspiration of the hepatic lesion yielded thick pus. Cultures of the pus and blood grew Streptococcus milleri. After treatment with ceftriaxone and penicillin V and percutaneous drainage of the liver abscess, the pulmonary and hepatic abnormalities resolved. S. milleri is part of the normal flora of the mucous membranes. The site at which it entered the patient's bloodstream was not evident.

Herbert L. Fred, M.D.
Shehzad Basaria, M.D.
University of Texas Health Science Center, Houston, TX 77030