Abstract Pyogenic liver abscess remains an uncommon but serious intra-abdominal complication which has a mortality rate of 4 to 20%. It presents with different clinical manifestations such as right upper quadrant pain, fever, and hepatomegaly. Respiratory symptoms are typically secondary to diaphragmatic irritation or transdiaphragmatic extension. However, isolated dyspnea without abdominal complaints is exceedingly rare and may mislead clinicians toward a primary pulmonary diagnosis. This case underscores the diagnostic challenge posed by massive hepatic abscess presenting solely as dyspnea and highlights the importance of considering subdiaphragmatic pathology in unexplained respiratory distress.A 31-year-old obese Filipino male nurse with hypertension and type 2 diabetes mellitus with a history of motor vehicular accident 4 months prior to admission presented at the clinic with progressive exertional dyspnea but denied fever, cough, or abdominal pain. On admission, he was afebrile, hemodynamically stable, with persistence of exertional dyspnea. Pulmonary examination revealed decreased breath sounds at the right base. Chest radiograph demonstrated right upper lung cicatricial atelectasis, elevated right hemidiaphragm, and minimal pleural effusion. Initial work-up for primary pulmonary pathology was unrevealing. Contrast-enhanced CT of the chest and abdomen incidentally revealed a large (23 × 16 × 15 cm) cystic mass occupying the right hepatic lobe, compressing the diaphragm and right lung base. CT-guided drainage yielded purulent material with high protein and LDH content, consistent with a hepatic abscess. No growth yielded on culture studies. The patient was treated with piperacillin-tazobactam and metronidazole, leading to marked symptomatic improvement and radiologic resolution of the abscess over two weeks.Dyspnea in hepatic abscess is commonly attributed to diaphragmatic irritation, pleural effusion, basal atelectasis, or rarely transdiaphragmatic rupture and empyema formation. In this patient, mass effect from a large subdiaphragmatic abscess restricted diaphragmatic excursion, producing a mechanical restrictive ventilatory defect that manifested solely as dyspnea. Absence of fever or abdominal pain delayed the management of hepatic abscess. This case highlights the need for a high index of suspicion and comprehensive imaging, including extension of thoracic CT into the upper abdomen, when respiratory symptoms lack a clear pulmonary etiology.This case demonstrates that hepatic abscess, though primarily an abdominal disease, can present exclusively with dyspnea through diaphragmatic and pleural involvement. Early recognition of this atypical presentation prevents delayed diagnosis and potentially life-threatening complications. Pulmonologists should maintain vigilance for subdiaphragmatic causes of respiratory distress, especially when imaging shows right hemidiaphragm elevation or unexplained pleural effusion. This abstract is funded by: None
Buan et al. (Fri,) studied this question.