Sir The coexistence of pulmonary and hepatic abscesses is most often due to transdiaphragmatic spread of a hepatic abscess, which can be either amoebic or bacterial, typically involving the lower lobe of the lung. We report a rare case of simultaneous lung and liver abscesses caused by distinct pathogens, highlighting the importance of considering dual pathology rather than assuming contiguous spread. A 44-year-old male manual laborer with recently diagnosed type 2 diabetes mellitus presented with a 2-month history of progressively worsening productive cough with purulent sputum Figure 1a, with intermittent hemoptysis and low-grade fever, and recent onset of right-sided pleuritic chest pain. There was no breathlessness, weight loss, or night sweats. He was an ex-smoker with occasional alcohol consumption and had received intermittent antibiotics at a local facility. He denied animal exposure, recent travel, and substance abuse, and had no other high-risk behaviors. On examination, he was hemodynamically stable. Respiratory system evaluation revealed dullness to percussion and coarse crepitations over the right infraclavicular and axillary regions. Laboratory investigations showed anemia (Hb 11.3 g/dL), leukocytosis (17,600/mm3), elevated erythrocyte sedimentation rate (62 mm/h) and CRP (34.1 mg/dL), and hypoalbuminemia. Chest radiograph demonstrated a right upper and middle zone opacity with an air–fluid level Figure 1b. Contrast-enhanced computed tomography (CT) thorax revealed a heterogeneously enhancing cavitary lesion with an air–fluid level in the right upper lobe, abutting the anterolateral chest wall, along with enlarged mediastinal lymph nodes Figure 1c and d.Figure 1: Purulent sputum (a); chest radiograph showing a right upper and middle zone air–fluid level (b); contrast-enhanced computed tomography (CT) thorax demonstrating a cavitary right upper lobe lesion with air–fluid level and mediastinal lymphadenopathy (c and d); CT abdomen showing a well-defined abscess in the posterior segment of the right hepatic lobe (e); and ultrasound-guided aspiration yielding anchovy sauce-colored pus (f)Sputum and bronchoalveolar lavage cultures grew Pseudomonas aeruginosa. Acid-fast bacilli were negative, bronchoscopy showed no endobronchial lesion, and cytology was negative for malignancy, confirming a bacterial lung abscess. Abdominal ultrasonography and CT revealed hepatomegaly with a well-defined abscess in the posterior segment of the right hepatic lobe Figure 1e. Ultrasound-guided aspiration yielded 75 mL of anchovy sauce-colored pus Figure 1f. While bacterial cultures were sterile, wet mount microscopy demonstrated motile trophozoites with pseudopods, consistent with Entamoeba histolytica, confirming an amoebic liver abscess. Importantly, there was no radiological evidence of transdiaphragmatic extension. The patient was initiated on piperacillin–tazobactam, clindamycin, and tinidazole, with marked clinical improvement. Follow-up ultrasonography after 9 days showed a significant reduction in abscess size. He was treated with 6 weeks of piperacillin–tazobactam, 10 days of tinidazole, followed by 10 days of diloxanide furoate, with marked clinical and radiological improvement at follow-up. Pleuropulmonary involvement associated with liver abscess is a well-recognized but uncommon complication, most frequently resulting from transdiaphragmatic rupture of a hepatic abscess into the pleural space or lung parenchyma, typically involving the right lower lobe and usually yielding the same etiological organism at both sites.1-3 Amoebic liver abscess complicated by secondary pleuropulmonary amoebiasis has been widely reported, particularly in resource-limited settings, where delayed diagnosis may predispose to rupture.1,4 Similarly, pulmonary abscess formation secondary to pyogenic liver abscess has been described, again attributed to direct extension or hematogenous spread, with concordant microbiological findings.2,5 More recently, Kim and Lee reported liver abscess complicating lung abscess, emphasizing the diagnostic challenge posed by anatomically contiguous infections.3 However, in all previously published cases, pulmonary involvement was secondary to hepatic disease and shared a common pathogen. In contrast, the present case is unique in demonstrating simultaneous lung and liver abscesses caused by distinct etiological agents, with Pseudomonas aeruginosa isolated from the lung and Entamoeba histolytica confirmed in the liver, and no radiological evidence of transdiaphragmatic extension. To our knowledge, no prior case has documented concurrent pulmonary and hepatic abscesses with differing microbiology, highlighting the importance of site-specific diagnostic evaluation, particularly in immunocompromised states such as diabetes mellitus. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Research quality and ethics statement The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report. We also certify that none of the authors is a member of the Editorial Board. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Mansoor C. Abdullah (Thu,) studied this question.