Gas-Forming Pyogenic Liver Abscess Suspected on a Plain Chest X-Ray

A 70-year-old man with a history of diabetes mellitus presented with weakness and poor oral intake for 1 month. On physical examination, he was febrile and had mild right upper quadrant tenderness. The patient's white cell count was 14,900/mm³, with 79.0% neutrophils. A chest radiograph showed an air-fluid level in the right-upper abdomen (Fig. 1). Computed tomography (CT) revealed a huge gas-forming liver abscess (Fig. 2). The patient underwent sonography-guided drainage, and was given intravenous antibiotics and insulin to control his diabetes. The culture of the pus grew Klebsiella pneumoniae. He recovered and was discharged.

Figure 1

The chest radiograph showed an air-fluid level in the right-upper abdomen.

Figure 2

Computed tomography revealed a huge gas-forming liver abscess (arrows).

The diagnostic tools for gas-forming pyogenic liver abscess (GPLA) are sonography and CT. On plain films, an air-fluid level or mottled gas pattern is the most common finding. Gas within the liver parenchyma is reported to be visible in up to 36% of patients with GPLA. Unless suspected, this may be mistaken for bowel gas. In our case, we saw an air-fluid level in the right upper abdomen in the plain X-ray, which enabled us to detect GPLA early.