An Unusual Cause of a Recurrent Liver Abscess in a Young Boy

Abstract

Question: A boy, 6 months of age and previously healthy, was evaluated for unexplained fever of 2 weeks' duration. He was ill appearing and had a high white blood cell count (19.5 Â 10 9 /L) and C-reactive protein (CRP) of 265 mg/L. The diagnosis of a liver abscess supposedly by a bacterial pathogen was made based on abdominal ultrasound (US) examination, which showed an abscess in the left lobe (segments 2 and 3). The abscess was drained and amoxicillin/clavulanic acid, which had been initiated before drainage, was continued for 5 weeks. Cultures of the drained purulent fluid and blood remained negative. The boy recovered fully and the fever disappeared. US examination 4 weeks after drainage showed a small cavity with clear fluid at the site of the initial abscess. Four weeks after the end of the antibiotic course, he presented again with fever and discomfort. Laboratory tests showed leukocytosis and elevated CRP; US examination showed recurrence of the liver abscess. The abscess was drained again and amoxicillin/clavulanic acid for 5 weeks was started. Four weeks into the second antibiotic course, he presented with feeding difficulties and bouts of painful crying. He had no fever and CRP was only mildly elevated (13 mg/L). On US examination, the liver abscess had decreased in size compared with 4 weeks earlier. However, an additional cystic structure between the stomach and liver, adjacent to the liver abscess, was noted. The cyst was hypoechoic and had a multiple layered wall (Figure A, arrow). Magnetic resonance imaging showed the liver abscess (Figure B, black arrow) and adjacent a tubular cyst between the liver and the antrum of the stomach (Figure B, white arrow), which was 1.3 cm in diameter and filled with clear fluid. What is the diagnosis of the cyst? What is the most likely cause of the recurrent liver abscess? Look on page 485 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.