A 69-year-old man presented to the emergency department with right upper quadrant abdominal pain that started after a fatty meal. His medical history included diabetes mellitus, hypertension and ischemic heart disease. His surgical history included coronary artery bypass grafting, appendectomy and an inguinal hernia repair. He was hemodynamically stable and afebrile with obstructive jaundice.

Physical examination demonstrate a right upper quadrant tenderness, murphy sign was negative. Lab tests exhibited, normal leukocystes, increased hepatocellular enzymes (total bilirubin 2.6 mg/dl, direct bilirubin 1.17 mg/dl) and liver function test abnormalities (GGT 1255 U/L, ALT 480 U/L, AST 297 U/L, ALP 194 U/L). An abdominal Ultrasonography revealed fatty liver and a normal size gallbladder without thickened walls,with gallstones without bile duct dilation . Even though US imaging did not demonstrate signs of an inflamed gallbladder, the patient was considered to have cholecystitis with obstructive jaundice due to a convincing clinical presentation and remarkable right upper quadrant tenderness, he was admitted to our surgical department and managed conservatively with intravenous antibiotics and supportive care. The patient improved clinically,lab tests was improved also, bilirubinemia was decreased to 1.9/0.7 mg/dl and he was discharged; interval cholecystectomy was recommended following an endoscopic ultrasound (EUS).

Two weeks after discharge the patient underwent an EUS, which demonstrated a gallbladder with gallstones and sludge. Biliary duct dilation of up to 6.4 mm with 2 filling defects were also visualized. An ERCP was recommended and performed a week and a half later. A papillotomy and stone fragment extraction using a balloon catheter and a basket were performed. After the ERCP, the patient was admitted to our department for observation. Twenty-four hours post-ERCP the patient developed a fever (38 °C), chills, hyperbilirubinemia (2.66/1.16 mg/dl) and elevated liver function tests (AST 224 U/L, ALT 121 U/L, ALP 160 U/L, GGT 570 U/L). Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, he continued to be febrile, confused and with chills. His physical examination was remarkable, his abdomen was diffusely tender and his lab tests reveal an increasing in inflammatory markers: C-reactive protein (CRP) 256 mg/l, leukocytosis 14(× 10 [3]/ul),with left shift 92% neutrophils. Also markedly hyperbilirubinemia was observed (total bilirubin 5.53 mg/dl), Blood cultures were drawn to rule out a viscous perforation. A computed tomography (CT) scan with double contrast of the abdomen and pelvis was done 3 days post-ERCP. A perforation was ruled out as no abdominal free air or fluids were found. Yet a very small hypodense lesion was found in the seventh liver segment (Fig. 1a).

On day 6 post-ERCP, the antibiotic regimen was changed to Ertapenem and Vancomycin, to treat possible multi-drug resistant pathogens. Two days later, extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified on blood cultures so antibiotics were switched to Imipenem and Cilastatin. Nonetheless, the patient continued to have abdominal pain. Upon examination, his abdomen was soft and distended, with no signs of peritonitis. CRP was elevated (160 mg/L), with mild leukocytosis (13 x 10e³/uL) and neutrophilia (83%). CT scan, with a double contrast of the abdomen and pelvis was repeated on day 7 post-ERCP revealing a hypodense irregular lesion that was found to increase in diameter, this finding was consistent with pyogenic liver abscess (Fig. 1b). Also, a hypodense lesion in the right psoas appeared (Fig. 2b), which was not seen on the first CT scan (Fig. 2a), it was decided to continue with antibiotic treatment without drainage. Two days after the antibiotic regimen was changed to Imipenem and Cilastatin, the abdominal pain subsided. He was afebrile and his liver function tests and bilirubin normalized. However, on day 10 post-ERCP, the patient began to complain about low back pain and difficulty walking. On physical examination, he had localized tenderness over the spinous processes of L4-L5, and reduced quadriceps femoris strength (3/5). A thoracolumbar spine magnetic resonance imaging (MRI) scan was recommended by a consulting orthopedic surgeon to evaluate for possible myelopathy or radiculopathy. MRI was performed on day 19 post ERCP, which revealed L4-L5 discitis,a large iliopsoas abscess on the right side,and other small abscess on the left side, an epidural abscess in front of spinal canal at level L1-D11 other one at level L2- S1 appearing to compress the spinal cord (Fig. 3). A diagnosis of spinal epidural abscess (SEA) with discitis and osteomyelitis was established. The patient was transferred to the orthopedic department and was urgently operated. Decompressive laminectomy of L5 was done and a large epidural abscess was drained and irrigated. Drainage catheters were placed, and the wound was closed in layers. Cultures from the pus were positive for Klebsiella pneumonia. Thus, IV antibiotics with polymyxin E and Gentamicin were initiated Post-operatively, and the patient’s back pain significantly subsided. Nonetheless, due to continued of serosanguineous drainage from the surgical incision, fever of 38.7^C, CT total body was performed on day 7 postoperative to evaluate epidural and liver abscess, exhibited a 4.8 cm hypodense irregular lesion at segment 7 of the liver,epidural and psoas abscess were increased in size (Figs. 1c,2c). patient was taken back to the operating room for other evaluation. The decompressive laminectomy was expanded to include L2-L4, and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. The patient was continued intravenous antibiotics with polymyxin E and Gentamicin. Two days later the patient was presented to the multidisciplinary panel (surgery and radiology) for further evaluation and discussion of liver and iliopsoas abscess treatment options. In light of the clinician and laboratory improvement it was decided to continue with a non invasive approach and to complete 6 weeks of antibiotic treatment. During the subsequent days the patient’s condition improved, the surgical incision was inspected without signs of infection or leak, and his lap tests normalized. Two months later,abdominal and spinal cord CT scan was performed as part of the follow up examination which assured almost complete regression of liver and iliopsoas abscess. An interval cholecystectomy was performed 6 weeks after discharging.