A 43-year-old Cambodian man was admitted to the hospital with fever, diarrhea, and jaundice. He reported symptoms of malaise, fever, night sweats, and abdominal pain starting one week prior. Examination revealed jaundice and a tender abdominal mass. Testing showed abnormal liver function and leukocytosis. Imaging found a large mass in the right hepatic lobe. Biopsies of the mass showed debris and inflammatory cells consistent with an abscess. The patient was treated with antibiotics and his condition improved with no identified cause of the abscess found.

1. CASO CIEGO 7-3-2012 (DR. MARTOS RUIZ)
A 43-year-old man was admitted to the hospital because of fever, diarrhea, and
jaundice.
He was well until one week earlier, when he experienced the onset of malaise,
fever, night sweats, anorexia, diffuse aches, and pain in the right upper
abdominal quadrant; two days later he became jaundiced. Four days before entry
diarrhea developed, and the patient noticed that his stools were lighter than
usual. Two days before admission he was seen at another facility with a
complaint of pain along the right costal margin. An x-ray film of the chest was
reported to show a questionable infiltrate in the right lower lobe. Amoxicillin
was prescribed. On the following day laboratory reports revealed leukocytosis
and abnormal results of tests of liver function, and the patient was referred to
this hospital.
The patient was a native of Cambodia, who immigrated to the United States
seven years before entry. Soon after his arrival in this country he was seen at
another facility, where he denied all symptoms and physical examination was
negative. A tuberculin skin test was positive; microscopical examination of a
stool specimen revealed cysts and trophozoites of Giardia lamblia, larvae of
Strongyloides stercoralis, and hookworm ova; a test on the serum for hepatitis B
surface antigen and antibody was negative. Metronidazole, thiabendazole, and
mebendazole were prescribed. Plans were made to begin isoniazid, but the
patient became lost to follow-up study. He worked as a house painter and carpet
layer; his wife and one child were alive and well. He had smoked 8 to 10
cigarettes daily for 14 years and used alcohol in moderation. He reported a loss
of 9 kg in weight during the week before entry. His father died of lung cancer.
The patient used no medications except acetaminophen. There was no history of
cough, chills, nausea, vomiting, hematochezia, melena, dark urine, hematuria,
hepatitis, gallbladder disease, tuberculosis or exposure to it, previous serious
illnesses, surgical procedures, allergy, intravenous drug abuse, exposure to toxic
materials, or neurologic symptoms.
The temperature was 39.2°C, the pulse was 100, and the respirations were 25.
The blood pressure was 150/80 mm Hg.
On examination the patient was thin, jaundiced, and drenched with sweat. No
rash or lymphadenopathy was found. The head was normal, and the neck was
supple. A few crackles were heard at both lung bases. The heart was normal.
The abdomen was tense, with normal bowel sounds; a slightly tender mass, 8
cm, was palpated; the spleen was not felt. No peripheral edema was found.
Neurologic examination was negative. Rectal examination was negative, and a
stool specimen gave a negative test for occult blood.
The urine was yellow and normal. The hematocrit was 31.3 percent; the white-
cell count was 19,900, with 67 percent neutrophils, 7 percent band forms, 5
percent lymphocytes, 9 percent atypical lymphocytes, 8 percent monocytes, and
4 percent metamyelocytes. The mean corpuscular volume (MCV) was 76 μm3
per cell, the mean corpuscular hemoglobin (MCH) 25.5 pg per red cell, and the
mean corpuscular hemoglobin concentration (MCHC) 33.5 percent. The platelet
count was 675,000, and the erythrocyte sedimentation rate 100 mm per hour.
The prothrombin time was 9.8 seconds, with a control of 10.5 seconds; the
partial thromboplastin time was 28.6 seconds. The urea nitrogen was 4.6 mmol
per liter (13 mg per 100 ml), the creatinine 97 μmol per liter (1.1 mg per 100

2. ml), the glucose 6.1 mmol per liter ( 110 mg per 100 ml), the uric acid 0.17
mmol per liter (2.8 mg per 100 ml), the conjugated bilirubin 77 mol per liter
(4.5 mg per 100 ml), the total bilirubin 96 μmol per liter (5.6 mg per 100 ml),
the calcium 2.0 mmol per liter (8.0 mg per 100 ml), the phosphorus 0.90 mmol
per liter (2.8 mg per 100 ml), and the protein 70 g (the albumin 22 g and the
globulin 48 g) per liter (7.0 g [2.2 g and 4.8 g] per 100 ml). The sodium was 132
mmol, the potassium 3.8 mmol, the chloride 99 mmol, and the carbon dioxide 24
mmol per liter. The serum aspartate aminotransferase (ASAT) was 63 U (new
normal, 10 to 40), the lactic dehydrogenase (LDH) 272 U (normal, 110 to 210),
the creatine kinase (CK) 26 U (new normal for a man, 60 to 400), the alanine
aminotransferase (ALAT) 41 U (new normal for a man, 10 to 55), and the
alkaline phosphatase 397 U per liter (new normal for a man, 45 to 115). An x-
ray film of the chest showed elevation of the right hemidiaphragm, with loss of
volume and atelectasis of the right lower lobe. An ultrasonographic study of the
right upper quadrant revealed a mass, 10 cm, with central hyperechoic areas, in
the right hepatic lobe; the bile ducts were not dilated. A computed tomographic
(CT) scan of the abdomen again disclosed a well-marginated mass, 11 cm, of
low attenuation, that lay in the right hepatic lobe, displaced the gallbladder
anteriorly, and bulged the fissure between the right and left hepatic lobes; no
calcification or gas was seen within the mass; linear opacities were observed at
both lung bases, with pleural thickening.
Specimens of blood and urine were obtained for culture. Ampicillin, gentamicin,
and metronidazole were administered by vein. On the second hospital day
physical examination showed no change. The temperature rose to 38.2°C. The
hematocrit was 29.7 percent; the white-cell count was 18,500, with 80 percent
neutrophils. The platelet count was 692,000, the reticulocyte count 1.4 percent,
and the erythrocyte sedimentation rate 119 mm per hour. The total eosinophil
count was 231 per cubic millimeter. The urea nitrogen was 2.0 mmol per liter (6
mg per 100 ml), the glucose 6.2 mmol per liter (111 mg per 100 ml), the
conjugated bilirubin 62 μmol per liter (3.6 mg per 100 ml), the total bilirubin 77
μmol per liter (4.5 mg per 100 ml), the iron 5.7 μmol per liter (32 μg per 100
ml), the iron-binding capacity 31.0 μmol per liter (173 μg per 100 ml), and the
protein 65 g (the albumin 20 g and the globulin 45 g) per liter (6.5 g [2.0 g and
4.5 g] per 100 ml). The sodium was 136 mmol, the potassium 4.5 mmol, the
chloride 104 mmol, and the carbon dioxide 20 mmol per liter. The LDH was 194
U, the alkaline phosphatase 360 U, and the 5'-nucleotidase 19 U per liter. A
percutaneous needle-aspiration biopsy of the hepatic mass, performed under
ultrasonographic guidance, yielded gross blood; microscopical examination of
stained specimens showed abundant red cells, a few neutrophils, and no
microorganisms; cytologic examination revealed scanty hepatocytes and a few
fibrous tissue fragments; pathological examination of the core-biopsy specimen
disclosed only hemorrhagic tissue. On the following day the patient felt better,
with improved appetite and no diarrhea. His temperature did not exceed 37.2°C
on that day, and he was afebrile thereafter. Physical examination was unchanged
except for an increase in tenderness over the right upper abdominal quadrant.
The hematocrit was 30.2 percent, the white-cell count 13,400, and the platelet
count 696,000. The conjugated bilirubin was 38 μmol per liter (2.2 mg per 100
ml), and the total bilirubin 50 μmol per liter (2.9 mg per 100 ml). The LDH was
194 U, and the alkaline phosphatase 354 U per liter. On the fourth hospital day

3. the patient reported that he felt well, and examination revealed no abdominal
tenderness. All bacteriologic cultures remained negative.
On the fifth hospital day the patient passed a normal stool. The ferritin was more
than 1000 μg per liter. A test on the serum for hepatitis B surface antigen and
antibody was negative. A percutaneous angiographic examination demonstrated
a large hypovascular mass in the right hepatic lobe that displaced arterial
structures; no evidence of arterial encasement was seen, and no early draining
veins or abnormal collections of contrast material were detected; the appearance
of the mass was considered not typical of a hepatoma. On the next day the
hematocrit was 34.9 percent; the white-cell count was 12,900, with 79 percent
neutrophils. The conjugated bilirubin was 22 μmol per liter (1.3 mg per 100 ml),
and the total bilirubin 34 μmol per liter (2.0 mg per 100 ml). The alkaline
phosphatase was 466 U per liter. An enzymelinked immunosorbent assay
(ELISA) on the serum for amebiasis was negative.
On the seventh hospital day a test on the serum for carcinoembryonic antigen
(CEA) was negative. Another percutaneous needle-aspiration biopsy of the
hepatic mass again yielded predominantly bloody liquid; pathological and
cytologic examination of the corebiopsy specimen showed debris, with admixed
histiocytes, acute inflammatory cells, and benign hepatic elements, consistent
with an abscess; there was no evidence of malignant-tumor cells, parasites,
fungi, acid-fast bacilli, or viral inclusions.
On the next day the patient continued to feel well; the abdominal mass was
unchanged and nontender. The hematocrit was 32 percent, the white-cell count
10,800, and the platelet count 680,000. The urea nitrogen was 4.0 mmol per liter
(10 mg per 100 ml), the creatinine 88 μmol per liter (1.0 mg per 100 ml), the
conjugated bilirubin 19 μmol per liter (1.1 mg per 100 ml), and the total
bilirubin 27 μmol per liter (1.6 mg per 100 ml). The alkaline phosphatase was
371 U, and the 5'-nucleotidase 24 U per liter. The alpha-fetoprotein was less
than 10 IU per milliliter. Microscopical examination of a stool specimen showed
no ova or parasites; moderate yeast forms were present. On the ninth hospital
day microscopical examination of another stool specimen again disclosed no ova
or parasites, and all bacteriologic cultures remained negative. On the 10th
hospital day the hematocrit was 33.7 percent; the white-cell count was 8200,
with 74 percent neutrophils. Ampicillin and gentamicin were discontinued;
metronidazole was continued. On the next day the patient remained
asymptomatic, and physical examination was unchanged. The urea nitrogen was
4.0 mmol per liter (10 mg per 100 ml), the creatinine 88 μmol per liter (1.0 mg
per 100 ml), the conjugated bilirubin 21 μmol per liter (1.2 mg per 100 ml), and
the total bilirubin 27 μmol per liter (1.6 mg per 100 ml).
On the 12th hospital day the hematocrit was 36.3 percent, the white-cell count
9700, and the platelet count 663,000. Microscopical examination of additional
stained specimens of the fluid aspirated on the seventh hospital day yielded no
evidence of parasitic infection. A magnetic resonance imaging (MRI) scan of the
abdomen (Fig. 1) showed a large solitary hepatic mass with long T1–weighted
and T2–weighted relaxation times centrally and short T1–weighted and T2–
weighted relaxation times in a capsule-like peripheral distribution that suggested
a chronic hematoma; an outer bright rim of long T2–weighted signal was
believed indicative of hepatic edema that surrounded the mass.
On the 13th hospital day a diagnostic procedure was performed.

4. Figura 1.