Visual Diagnosis in Emergency Medicine GAS-FORMING LIVER ABSCESS WITH PNEUMOCARDIA Li-Ta Keng, MD,* Yang-Hsien Fu, MD,† and Yen-Huai Lin, MD‡ *Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan, †Department of Internal Medicine, and ‡Department of Radiology, Kinmen Hospital, Kinmen, Taiwan Reprint Address: Li-Ta Keng, MD, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, No.25, Ln. 442, Sec. 1, Jingguo Rd., North Dist., Hsinchu City 300, Taiwan (R.O.C.) CASE REPORT A 76-year-old man with a history of diabetes mellitus pre- sented to the emergency department with spiking fevers lasting for 1 week. On physical examination, his temper- ature was 38.9  C. The sclerae were icteric, and there was tenderness when knocking on his right lateral lower costal area. Laboratory studies revealed an increased white blood cell count (11,680/mL), elevated liver enzymes (aspartate aminotransferase 379 units/L; alanine amino- transferase 237 units/L) with hyperbilirubinemia (total bilirubin 3.97 mg/dL), and acute kidney injury (blood urea nitrogen 24 mg/dL [normal range, 7–18]; creatinine 1.7 mg dL [normal range, 0.8–1.3]). A posteroanterior chest radiograph (Figure 1) showed some lucencies over the right upper quadrant. An emergent abdominal computed tomography scan revealed extensive necrosis with gas formation at the right hepatic lobe (Figure 2), and air within the right ventricle (Figure 3). The clinical picture was compatible with a gas-forming liver abscess, complicated with pneumocardia. The patient was treated with broad-spectrum antibiotics, and was transferred to a tertiary medical center for abscess drainage. The final blood culture yielded Klebsiella pneumoniae. He was discharged on the 23 rd hospital day. Figure 1. Posteroanterior chest radiography showed some lucencies over the right upper quadrant (arrow). RECEIVED: 27 August 2013; FINAL SUBMISSION RECEIVED: 6 December 2013; ACCEPTED: 31 January 2014 1 The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2014.01.021