Intrahepatic Cholangiocarcinoma Masquerading as Liver Abscess

Abstract

Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis. Primary liver tumors such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as non-resolving liver abscess is extremely uncommon and carries a dismal prognosis. We present a rare case of non-resolving liver abscess as a presenting manifestation of intrahepatic cholangiocarcinoma. ( J CLIN EXP HEPATOL 2015;5:89-92) F ebrile illness due to amoebic or pyogenic liver abscesses is frequently seen in tropical countries. Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis 1 and neuroendocrine tumors. 2 Fever maybe due to tumor necrosis getting liquefied and transforming into abscess, or due to release of cytokines, or due to paraneoplastic manifestation. Primary liver tumor such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as liver abscess is extremely uncommon. 3,4 We report here a case of intrahepatic cholangiocarcinoma which masqueraded as a non resolving liver abscess. CASE REPORTA 57-year-old male, known case of type-2 diabetes mellitus, on oral hypoglycaemic agents for last 10 years, presented to us with 2-month history of low-grade intermittent fever, not associated with chills and rigor.The fever used to be in the range of 100 -101 F, not associated with any chills, rigors, or night sweats, and used to occur daily. There was no history of weight loss, pain abdomen, cough, jaundice, pruritus or any clinical feature of cholangitis. Prior to admission to our hospital, he had been investigated for the cause of fever at another medical center. Urine, blood cultures, Widal, typhoid serology and amoebic serology had been negative. His radiological investigations in the form of USG and CT abdomen (Figures 1 and 2) showed right lobe hypoechoic and hypodense, multi-septate lesion of size 7 cm  6 cm with irregular shaggy margins consistent with liver abscess. There was no evidence of any central or segmental intrahepatic biliary radical dilatation and the common bile duct was normal in size. Based on these findings, he was treated as a case of liver abscess, and received third generation cephalosporins plus antiprotozoal for 2 weeks. However, there was no abatement in his fever range, intensity or frequency. Hence, he was referred to our hospital.At presentation to our hospital his physical examination revealed pallor, a 2 cm tender hepatomegaly, but no splenomegaly. His investigations were as follows: Hb 10.9 g/dL, WBC 8.1  10 3 /mL, platelets 140  10 3 /mL, ESR 86 mm at 1 h, serum creatinine 0.53 mg/dL, serum bilirubin 0.3 mg/dL, AST 24 IU/L, ALT 32 IU/L, SAP 186 IU/L, and GGT 214 IU/L. Urine routine and microscopy examination was normal. Blood and urine cultures were sterile. Serum procalcitonin level was 0.28 ng/ml, Widal test was negative, amoebic and hydatid serologies were negative. His virology studies for HBV, HCV an...

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“…Fourth, we could not conduct a subgroup analysis of patients with fever between the two groups, due to the small number in the IMCC group. Finally, cases in which the patient present both LA and IMCC require a careful approach on the part of the clinician to identify both entities; however, IMCC presenting primarily as liver abscess is extremely rare [ 33 ].…”