What is the diagnosis for a patient with sudden onset of abdominal pain, 2 days of fever with rigors, tenderness in the right upper quadrant (RUQ) and costal margin, enlarged tender liver, hyperthermia (temperature 38), leukocytosis (total leukocyte count (TLC) 13000), and mildly elevated serum glutamic-pyruvic transaminase (SGPT) and serum glutamic-oxaloacetic transaminase (SGOT) with alkaline phosphatase (ALP) within normal limits?

Diagnosis: Liver Abscess

The clinical presentation strongly indicates a pyogenic liver abscess rather than viral hepatitis. The combination of sudden onset RUQ pain, fever with rigors, tender hepatomegaly, leukocytosis (13,000), and mildly elevated transaminases with normal alkaline phosphatase is classic for liver abscess 1, 2, 3.

Key Distinguishing Clinical Features

Fever with rigors and tender hepatomegaly are hallmark findings of pyogenic liver abscess that differentiate it from viral hepatitis 1, 4, 5:

• Pyogenic liver abscess typically presents with:

  • High fever (often >38°C) with rigors/chills 1, 2, 3
  • RUQ pain and tenderness 1, 4, 5
  • Enlarged, tender liver on palpation 4, 5
  • Leukocytosis (elevated WBC count) 1, 2
  • Mildly elevated transaminases (SGPT/SGOT) 5
  • Elevated alkaline phosphatase in 78% of cases, though it can be normal 5

• Viral hepatitis typically presents with:

  • Gradual onset of symptoms
  • Jaundice (more prominent than in abscess)
  • Markedly elevated transaminases (often >10x normal)
  • Normal or minimally elevated WBC count
  • Non-tender hepatomegaly
  • Absence of rigors

Diagnostic Approach

Abdominal ultrasound should be performed immediately as the initial imaging modality 6:

• Ultrasound is the first-line diagnostic test for suspected hepatic abscess in patients with RUQ pain and fever 6
• It can reliably identify liver abscesses and guide percutaneous drainage 6, 5
• If ultrasound is equivocal or unavailable, CT abdomen with IV contrast should be obtained 6

Blood cultures and abscess aspiration cultures are essential to identify the causative organism 7, 1, 3:

• Common pathogens include Klebsiella pneumoniae, E. coli, and anaerobes 7, 2
• Cultures guide targeted antibiotic therapy 7, 3

Critical Pitfall to Avoid

Do not delay imaging based on normal alkaline phosphatase levels. While elevated ALP is common in liver abscess (78% of cases), it can be within normal limits as in this patient 5. The clinical triad of fever with rigors, RUQ tenderness, and hepatomegaly mandates immediate imaging regardless of liver enzyme patterns 1, 4, 5.

Why Not Viral Hepatitis?

The clinical presentation argues strongly against viral hepatitis:

• Rigors are uncommon in viral hepatitis but characteristic of pyogenic infections 1, 2
• Sudden onset over 2 days is atypical for viral hepatitis, which usually has gradual onset
• Leukocytosis (13,000) suggests bacterial infection; viral hepatitis typically shows normal or low WBC 1, 2
• Only mildly elevated transaminases - viral hepatitis usually causes marked elevation (often >500-1000 IU/L)
• Tender hepatomegaly is more consistent with abscess than viral hepatitis 4, 5