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A 58 year old male patient presented with a 24 hour history of nausea, vomiting, and right shoulder tip pain with associated rigors. On examination he was tachycardic, 100 beats per minute, and pyrexial (38°C) but clinical examination was otherwise unremarkable. He was taking no medications and the only previous medical history of note related to a large birthmark on his leg which had been investigated when he was a child but had not required intervention. Initial laboratory investigations were also within normal limits apart from an elevated white cell count of 15.5×109/l and an elevated serum alkaline phosphatase of 256 U/l (normal range 44–132).
A chest radiograph revealed no focal lung lesion. Blood cultures were obtained prior to commencement of antibiotic therapy and Streptococcus pneumoniae was isolated, the source of which was unclear. In view of the abnormal liver function, ultrasound of the liver was undertaken and this demonstrated a 9 cm hyperechoic mass in the right lobe atypical for an abscess and suggestive of a tumour. The patient proceeded to computed tomography of the upper abdomen for further assessment and an unenhanced section through the right lobe of the liver and spleen is shown in fig 1.
What abnormalities are present? What is the explanation for the bacteraemia? What is the likely diagnosis?
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This case is submitted by:
Robin Spiller, Editor