Endgames Case Report

A mass in the liver

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2036 (Published 03 April 2013) Cite this as: BMJ 2013;346:f2036
  1. Alex Mentzer, core medical trainee,
  2. Michael Jacobs, consultant
  1. 1Department of Infectious Disease, Royal Free NHS Foundation Trust, London NW3 2QG, UK
  1. Correspondence to: A Mentzer alexmentzer{at}doctors.net.uk

A 38 year old woman presented with a three day history of fever, generalised myalgia and arthralgia, and the sensation of difficulty when breathing in. She had poorly localised discomfort in the left diaphragmatic region on deep inspiration. Her stools had been loose over the preceding three days but she had no other symptoms. Three days before presentation she had returned from a three week trip to Western Australia and 18 months earlier she had travelled to Vietnam.

On examination she appeared well but was febrile at 38.0°C. She was tachypnoeic at 22 breaths/min, but all other observations were normal. Examination of all other systems was unremarkable. Blood tests showed severe neutrophilia (18.9×109/L; reference range 2.0-8.1), a raised C reactive protein (354 mg/L; reference value <10; 1 mg/L=9.52 nmol/L), and normal renal and liver biochemistry. Chest radiography and urinalysis were normal.

After two days of empirical treatment with intravenous co-amoxiclav (1.2 g three times daily) and oral doxycycline (200 mg once daily), her condition had not changed. She continued to have fevers up to 39.5°C, and her inflammatory markers remained high. Blood cultures taken at presentation were negative.

Computed tomography of the chest, abdomen, and pelvis with intravenous contrast showed a rim enhancing abscess in the left lobe of the liver and a filling defect in the portal vein consistent with portal vein thrombosis.

Questions

  • 1 What is the differential diagnosis?

  • 2 Which further investigations or procedures would you undertake?

  • 3 What treatment would you start?

  • 4 What are the potential complications of this condition?

Answers

1 What is the differential diagnosis?

Short answer

The main differential diagnosis of a large mass in the liver is a pyogenic or an amoebic liver abscess. A hepatic cyst complicated by haemorrhage or secondary infection could also present in a similar clinical way.

Long answer

The clinical presentation and computed tomography findings (figure …

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