Iaxone, metronidazole, gentamicin and paracetamol. He had a white cell count of 24.8?09/l and also a lactate of two.two mmol/l. The chest radiograph had the look of free of charge air beneath the diaphragm (figure 1). The abdominal CT scan showed a big liver abscess, with a second smaller uncomplicated cyst not shown (figure 2).INVESTIGATIONSChest radiograph together with the appearance of free of charge air beneath the diaphragm. Abdominal CT scan displaying a sizable liver abscess 21?7?six cm with an air fluid level within the appropriate lobe, with a second smaller sized 1.1 cm very simple cyst in segment VI. There was no evidence of cholecystitis, diverticulitis or other intra-abdominal infection.DIFFERENTIAL DIAGNOSISPyogenic abscess, amoebic abscess, fungal abscess, hydatid cyst, metastatic and key hepatic tumours, cholecystitis, and gastritis.CASE PRESENTATIONA 69-year-old man was referred to the accident and emergency division having a diagnosis of suspected atrial fibrillation with rapid ventricular response produced by a general practitioner.Formula of 162405-09-6 Additional questioning revealed a 2-month history of intermittent abdominal pain, anorexia, weight-loss and malaise.1186127-11-6 web He reported losing ten kg over the last 2 months. He had collapsed 3 occasions and so had ceased his antihypertensives. He spent the final 7 days vomiting, with typically 4 episodes every day and constipation. He had been passing flatus. He also reported 4 days of worsening shortness of breath and light-headedness. His health-related history incorporated hypertension, paroxysmal atrial fibrillation, symptomatic initial degree heart block for which he had a pacemaker in situ and benign prostatic hypertrophy.PMID:23554582 Medicines included metoprolol, doxazosin, lisinopril, hydrochlorothiazide, digoxin and terazosin. He had by no means been a smoker, with minimal alcohol consumption and lived alone. He had been a space research scientist who had recently moved to London from California.To cite: Rusman J. BMJ Case Rep Published on-line: [please involve Day Month Year] doi:10.1136/bcr-Figure 1 The chest radiograph with all the appearance of no cost air beneath the diaphragm.Rusman J. BMJ Case Rep 2013. doi:10.1136/bcr-2013-Reminder of important clinical lessoncultures are crucial to guide antibiotic therapy. Although the clotting studies are disordered, aspiration and drainage are relatively contraindicated. Aspiration and radiologically guided drainage, with an acceptable course of antibiotics and antifungals if a fungal abscess is suspected, guided by microscopy, culture and sensitivity studies resolves most liver abscesses; however, a modest percentage need further surgical intervention like laparotomy.24 Numerous studies point to either a co-committant cancer,25 or an elevated threat of colorectal cancer following a liver abscess diagnosis26 with one study27 reporting an adjusted HR of colorectal cancer of 2.7 times for sufferers diagnosed using a K pneumonia liver abscess compared to the typical population, and recommend that further research must be undertaken for the detection of occult cancers in these sufferers. A liver abscess may well herald malignancy. Figure two The abdominal CT scan showed a big liver abscess, with a second smaller simple cyst not shown.Mastering points Liver abscesses may well mimic malignancy and thus are an important differential to think about when presented with the clinical indicators of discomfort, fevers and weight-loss. The appearance of no cost air beneath a diaphragm on chest radiograph is just not often bowel perforation. Liver abscesses are frequently successfully treated with r.