Liver abscess presenting with dyspnea and right-side neck pain that

This is an open access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/).

Submitted: 08 July, 2021 Accepted: 10 August, 2021 Published: 08 January, 2023 DOI:10.22514/sv.2021.213

C A S E R E P O R T

Liver abscess presenting with dyspnea and right-side

neck pain that can be overlooked in the emergency

department: a case report

Sangun Nah

, Young Soon Cho

,†

, Sangsoo Han

,†

Department of Emergency Medicine,

Soonchunhyang University Bucheon

Hospital, 14584 Bucheon, Republic of

Korea

*Correspondence

[email protected]

(Young Soon Cho);

[email protected]

(Sangsoo Han)

†

These authors contributed equally.

Abstract

Liver abscess is a potentially fatal mass associated with liver injury and disease with

a mortality rate of 12% if treatment is delayed. Patients usually complain of fever

or upper abdominal pain; however, atypical symptoms, such as right shoulder pain,

may also appear. We report a case of liver abscess presenting as dyspnea and right-

side neck pain without any other symptoms. A 78-year-old man visited the hospital

complaining of right-side neck pain, which had persisted for 10 days, and dyspnea that

developed over time. The neck pain and dyspnea were aggravated with changes in

posture. Arterial blood gas results (pH 7.47, PO

76 mmHg, PCO

33 mmHg, SpO

98%) and chest and neck X-rays were normal, but white blood cell and C-reactive protein

levels were higher than normal. A contrast-enhanced computed tomography scan of the

chest was performed to differentiate the unexplained dyspnea and neck pain, and the liver

abscess, which was diagnosed accidentally. Clinicians should consider liver abscess as

a differential diagnosis in patients with dyspnea or neck pain when there is an increase

in inflammatory marker, but it is difficult to explain the cause.

Keywords

Liver abscess; Phrenic nerve; Dyspnea; Neck pain; Referred pain

1. Introduction

A liver abscess is a lump of pus formed inside the liver caused

by liver injury, direct contact with a biliary tract infection,

or leakage from another intraperitoneal abscess via the portal

vein [1]. The most common risk factor is diabetes mellitus

(DM), and other risk factors include malignancy, liver cirrho-

sis, and biliary or pancreatic disease. The current mortality

rate from a liver abscess is 0.5–4% (owing to the development

of effective drainage methods and antibiotics against specific

microorganisms), but if treatment is delayed it rises to 12%

[1]. The representative symptoms of liver abscess are fever or

upper abdominal pain, which occur in about 90% of patients

[2]. Other symptoms include chills, nausea or vomiting, and

atypical symptoms such as hiccups or right shoulder pain [1, 3].

We report a case of liver abscess presenting with dyspnea

and neck pain, which are different from the previously known

atypical symptoms.

2. Case presentation

A 78-year-old man visited the hospital complaining of right-

side neck pain and dyspnea, and he stated that he had no

fever before the presentation. The patient had developed

persistent right-side neck pain for 10 days, and was taking a

nonsteroidal anti-inflammatory drug (NSAID). However, no

improvement in the neck pain was observed and the newly

developed dyspnea persisted for 2 days. The patient was a

non-smoker and did not drink alcohol regularly. And he had

no specific traumatic history had DM and hypertension.

The initial vital signs were blood pressure 160/100 mmHg,

body temperature 36.8

◦

C, heart rate 68 bpm, respiratory rate

21 bpm, and SpO

98%. He complained of tingling pain

from the right side of the neck to the right shoulder and his

numerical rating scale for pain was 5. Dyspnea improved in

the sitting position but worsened in the supine or right lateral

recumbent position, and the pain had the same pattern. No

tenderness was detected at the site of the self-reported pain.

Laboratory findings were white blood cells 17,680/mm

, C-

reactive protein 18.06 mg/dL, brain natriuretic peptide 170

pg/mL, troponin T 0.006 ng/mL, aspartate transaminase 37

U/L, alanine transaminase 17 U/L, alkaline phosphatase 217

U/L, and total bilirubin 1.83 mg/dL; arterial blood gas pH

7.47, PO

76 mmHg and PCO

33 mmHg. No abnormali-

ties were detected in chest, shoulder, and neck X-rays, and

electrocardiography indicated a normal sinus rhythm. A neck-

chest contrast-enhanced computed tomography (CT) scan was

performed; an about 8.3 cm peripheral enhancing septated

mass was found in liver segments 2, 3, and 4 in the chest CT,

so the patient was admitted to the gastroenterology department

under the diagnosis of a liver abscess (Fig. 1A,B). Ultrasound-

158

F I G U R E 1. Contrast-enhanced computed tomography scan of the 8.3 cm liver abscess in segments 2, 3, and 4. (A)

Horizontal view; (B) coronal view.

TA B L E 1. Summary of clinical information of five cases reported as phrenic nerve irritation caused by a liver abscess.

Author Sex/age Clinical presentation and symptoms

Lee et al. [3] Male/56 Hiccups, fever, tachycardia, and right shoulder pain

Park et al. [5] Male/31 Right shoulder and posterior neck pain

Subramaniyam et al. [7] Male/mid-40s Fever and right-sided neck pain

Williams et al. [6] Male/18 Abdominal, shoulder pain, fever, night sweats, weight loss, and malaise

Present case Male/78 Dyspnea and right-side neck pain

guided percutaneous drainage was performed, and a percu-

taneous catheter was inserted. The abscess culture yielded

Klebsiella pneumonia. The patient discharged on day 11 of

hospitalization after removing the percutaneous catheter. The

dyspnea and neck pain gradually improved. There were no

unusual findings at follow-up 2 weeks later.

3. Discussion

We report a patient with liver abscess who complained of

dyspnea and right-side neck pain. These symptoms are thought

to have been caused by irritation of the phrenic nerve due to

the liver abscess, which was located in the sub-diaphragmatic

area. According to previous reports, atypical symptoms such

as right shoulder pain can occur when phrenic nerve is irritated

by a liver abscess [1, 4]. Five cases of phrenic nerve irritation

caused by a liver abscess, including our case, are presented in

Table 1 (Ref. [3, 5–7]). Common symptoms of liver abscess

are fever and/or abdominal pain. However, in our case, there

were only accompanying neck pain and dyspnea, revealing a

different pattern from previous reports.

The phrenic nerve, which is a sensory/motor nerve from

the C3–5 spinal nerve, innervates the central tendon of the

diaphragm, the pericardium (the membrane lining the heart),

and the outer lining in the medial region of the lungs (parietal

pleura), sending sensory information to the brain [8]. The

phrenic nerve is important because it plays a critical role

in breathing by controlling the diaphragm [4]. Therefore,

respiratory dysfunction can occur when this nerve is injured or

irritated. This respiratory dysfunction can occur by stimulating

the diaphragm with compression, infection, or trauma, and can

cause patients to complain of symptoms such as orthopnea,

dyspnea, and cough [9]. In our case also, the liver abscess

stimulated the diaphragm, which may have contributed to the

patient’s dyspnea. The irritation of phrenic nerve may cause

specific referred pain such as shoulder pain [1, 3, 5]. Well-

known examples of such pain include Kehr’s sign caused by

injury or disease to the spleen [5]. Such pain is caused by

a projection to a somatic area innervated by the same spinal

segment where the nerve irritation occurs [10, 11]. In our

case, the liver abscess irritated the phrenic nerve located in the

diaphragm, so the right-side neck pain may have been caused

by the same spinal nerve supply (C3–5) shared by the phrenic

and somatic nerves. However, if the abscess was remote from

the liver capsule, the symptoms due to phrenic nerve irritation

would not be to occur.

Klebsiella pneumonia infection may occur in patients with

predisposing factors like DM or alcohol use disorder [12]. In

patient with liver abscess caused by Klebsiella pneumonia,

cervical epidural abscess might be considered if the patient

159

complains of neck pain [13]. In our case, although the patient

had DM, cervical epidural abscess did not develop.

In summary, it is uncommon for a patient with a liver abscess

to complain of dyspnea or right-side neck pain without any

other symptoms. In our case, it is thought that the symptoms

commonly associated with liver abscess, such as fever and ab-

dominal pain, were masked by the NSAID that the patient was

taking. Clinicians should consider a liver abscess in patients

with dyspnea and/or neck pain when there is an increase in

inflammatory marker, but it is difficult to explain the cause.

AUTHOR CONTRIBUTIONS

SN examined the patient and diagnosed the case. SN wrote the

first version of the manuscript. YSC and SH approved the final

version of the paper and edited it. All authors contributed to

the final version of the manuscript.

ETHICS APPROVAL AND CONSENT TO

PARTICIPATE

The study protocol was approved by the Institutional Review

Board of Soonchunhyang University Bucheon Hospital (IRB

file no. 2021-05-035). Informed consent was obtained from

the patient involved in the study.

ACKNOWLEDGMENT

Thanks to all the peer reviewers for their opinions and sugges-

tions.

FUNDING

This research was funded by the Soonchunhyang University

Research Fund, grant number 10210044.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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How to cite this article: Sangun Nah, Young Soon Cho,

Sangsoo Han. Liver abscess presenting with dyspnea and right-

side neck pain that can be overlooked in the emergency

department: a case report. Signa Vitae. 2023; 19(1): 157-159.

doi: 10.22514/sv.2021.213.