A 75-year-old woman presented to the emergency department with a 300 mg/dL capillary glucose test.
She had been prescribed oral antidiabetic agents (Glibenclamide) and daily glycemic controls for four days.
The patient also reported a self-limited episode of epigastric and right hypochondrium pain for 6 days with nausea and vomiting and that she related to taking a fish in doubtful poor condition.
As a personal history, she only reported following treatment with Indapamide Retard for hypertension.
She was asymptomatic at that time.
The physical examination of the patient was strictly normal, with no abdominal pain.
Blood tests showed leukocytosis of 23,000/mm3 with left shift and biochemistry, blood glucose of 190 mg/dL and normal amylase with mild elevation of lipase; bilirubin and transaminase were normal.
We performed an abdominal plate and an abdominal ultrasound in which gallstones were observed and signs suggestive of acute colitis in the gallbladder were observed.
The patient was admitted to an absolute diet with antibiotic coverage and persistence.
The patient was satisfactorily tolerated well and was discharged after five days.
Two days after discharge, the patient presented with fever in peaks of up to 40oC without apparent source.
Physical examination was normal again except for fever.
Laboratory tests revealed only leukocytosis (24,000/mm3) with left shift, mild hyperglycaemia and normal pancreatic enzymes without a pattern of stasis.
Urinary sediment and chest and abdominal plaques were also normal.
A new imaging test was performed, including abdominal computed tomography (CAT).
The pancreas was completely unstructured in relation to pancreatitis and biliary strictures without biliary dilatation were observed.
We also identified a rounded low attenuation image (20 HU) in the hepatic hilium of 6.5 per 5 cm, without gas or enhancement, surrounding the portal and the inferior vena cava and extending through the aorta.
On the other hand, segment 8 of the right hepatic lobe showed a 1.5 cm lesion compatible with liver abscess accompanied by perfusion defect in relation to thrombosis of the segmental branch of the portal.
Laboratory and biochemical tests were normal except for leukocytosis with a known left shift.
Empirical treatment was started with piperacillin-tazodone.
The patient then began to present systolic blood pressures of 70 and 60 mm Hg accompanying the febrile peaks, requiring hemodynamic support.
An antibiotic-sensitive E. coli was isolated in the hemocultives, but although the patient's situation improved clinically, we continued to have a trimettox due to the fact that we did not reduce it but began to have febrile.
Since then fever disappeared and abscesses were re-established, except for the liver, which required percutaneous drainage.
A coli and Klebsiella pneumoniae grew in the culture of this bacterium, which had not previously grown in the blood cultures and was resistant to ciprofloxacin-tatoxazolam and sensitive to trimethoprim-seromethoprim.
The patient recovered satisfactorily and her fever disappeared and her glycemic control was normal.
She was referred for scheduled cholecystectomy.
