Introduction: Actinomyces are a rare cause of the intra-abdominal infection that results in chronic suppurative and infectious granulomatous disease. Diagnosis of hepatic actinomycosis is often difficult because of its indolent clinical course and nonspecific radiological findings, which can be easily misdiagnosed as a primary liver cancer if it is solitary or as a metastatic tumor if it is multiple with imaging features.

Case Presentation: Here we present an interesting case of a 61-year-old female with history of uncontrolled diabetes mellitus type 2 who presented with hyperbilirubinemia, elevated international normalized ratio (INR), ascites and abdominal pain. Labs were revealing for Na 134, K+ 2.9, Total bilirubin 2.5, AST 80, ALT 50, CRP 1.5, AFP negative, INR 1.6, Hgb 9.7, and platelets 93. Workup for worsening liver function was non-revealing and patient denied any prior history of liver disease, IV drug use, viral hepatitis, alcohol abuse, or family history of liver disease. Hepatitis panel was non-reactive. A CT Abdomen & Pelvis was done which showed mesenteric abscesses measuring 5.2 x 4.5 cm enhancing, and multiple ill-defined masses within the right and left hepatic lobes, suggesting liver metastases. General surgery was consulted, and patient underwent right hemicolectomy for resection of mesenteric mass and liver biopsies were sent for pathology which was revealing for Actinomyces. Infectious disease was consulted, and patient was treated with Penicillin G as an outpatient with close follow up of 12 months.

Final Diagnosis: Isolated hepatic actinomycosis is an uncommon infectious disease that can mimic multiple disease processes. It may present as a malignant disease, with symptoms of abdominal pain, asthenia, and weight loss. High index of suspicion is needed to avoid delay in diagnosis.

Management/Outcome: Confirmation is done by FNA or core biopsy by surgical exploration or radiological guided biopsy. The exclusion of malignancy is one of the main purposes of investigation, especially when patients present with liver masses associated with other hepatic symptomatology. In many patients prolonged treatment of high dose penicillin is required to be cured such as in this patient.

References and Resources

1. https://www.sciencedirect.com/science/article/abs/pii/0002961081902038
2. https://www.scopus.com/record/display.uri?eid=2-s2.0-0025318921&origin=inward&txGid=13926ecd4c9202d1dd3a6afb2684da8a
3. https://www.hindawi.com/journals/criid/2017/1972023/