A multiple choice answer?

A 49-year-old man with a history of hypertension presented to our hospital with a 2-week history of sharp pain in the right upper abdomen and right lower chest radiating to the back. The patient reported a few days of fevers, chills, drenching night sweats, shortness of breath, malaise, and fatigue. He denied recent travel. Vital signs were temperature 38.4 C, blood pressure 119/74 mmHg, heart rate 95 beats/minutes, respiratory rate 16 breaths/minutes, and oxygen saturation 96% on 5 L nasal cannula. Physical examination revealed poor dentition, right upper abdominal quadrant tenderness, and dullness to percussion over the right lung base. Initial labs showed white blood count (WBC) 22,540/ mm, alkaline phosphatase 280 units/L, bilirubin 1.1 mg/dL, aspartate aminotransferase (AST) 28 units/L, alanine aminotransferase (ALT) 33 units/L. Blood cultures were negative. An human immunodeficiency virus (HIV)1/HIV2 antibody screen was negative. Computed tomography (CT) of the chest demonstrated a large cystic lesion in the diaphragmatic dome of the liver with multiple lesions in the right lobe of the liver. Elevation of the right hemidiaphragm and moderate right pleural effusion were noted. CT abdomen showed multiple areas of fluid collection within the liver suspicious for liver abscesses (see Figure 1). Multiple gallstones were seen within gallbladder with a large stone in the region of the gallbladder neck vs. cystic duct without evidence of extrahepatic biliary dilatation. There was mild distention of the appendix with minimal soft tissue stranding. The patient underwent ultrasound-guided drainage of the largest liver abscess. Cultures from the aspiration grew Fusobacterium nucleatum. The patient’s stool studies for ova and parasites were negative. The patient was started on piperacillin/tazobactam and metronidazole, then switched to ertapenem. A hepatobiliary iminodiacetic acid (HIDA) scan confirmed cholecystitis, and the patient underwent open cholecystectomy. Pathology on the gallbladder returned as chronic cholecystitis with cholelithiasis. A full dental examination revealed possible periapical abscesses of teeth #12 and #30 and stringent daily oral hygiene was recommended. Tooth extraction was initially recommended but ultimately postponed. Plans were made for dental follow-up. With continued antibiotic treatment, the patient’s fevers resolved and leukocytosis improved. A follow-up CT abdomen/pelvis obtained on hospital day 10 showed a reduction in size of the multiple liver abscesses. There was also increased prominence of the appendix with mild stranding. The patient was taken for appendectomy. Pathology was consistent with acute appendicitis with focal fat necrosis. The patient was ultimately discharged with the plan being to continue ertapenem until radiographic resolution of all the abscesses was demonstrated.