A 64-year-old man with a history of colonic resection for adenocarcinoma six years earlier presented with weakness and abdominal discomfort of six months' duration. Computed tomography of the abdomen with administration of contrast material showed multiple hypodense lesions involving the liver. The process on the liver appeared to cross the capsule and peritoneal membrane (arrow, Panel A). There was a small lesion in the upper pole of the spleen. Cultures of a specimen obtained by fine-needle aspiration of a liver lesion showed only Actinomyces israelii (inset). The patient was started on intravenous ampicillin and sulbactam. After eight weeks, a prominent indurated, erythematous swelling developed in his right flank and did not track along the needle-aspiration pathway; the swelling subsequently developed a central draining sinus tract (Panel B). Gram's staining revealed filamentous, beaded gram-positive rods consistent with actinomyces (arrows, Panel A inset). There was no evidence of recurrent cancer on biopsy. The patient has received intravenous antibiotics for seven months, with resolution of the drainage and slow improvement in the size of the liver collections.
Saad M and Moorman J. N Engl J Med 2005;353:e16
