Pyogenic Liver Abscess Secondary to Acute Appendicitis: A Case Report

Background: Pyogenic liver abscess is uncommon in children, and acute appendicitis as an underlying cause is now exceedingly rare, having been replaced by hepatobiliary diseases as the leading etiology. When appendicitis does lead to hepatic abscess formation, the diagnosis is often delayed because children may present with nonspecific symptoms that mimic other common paediatric illnesses. This case highlights the diagnostic challenge posed by an 11-year-old boy whose appendicitis-related liver abscess initially presented with fever and altered consciousness, leading to a mistaken suspicion of meningitis. The report emphasizes the need to maintain a high index of suspicion for abdominal pathology in febrile children with unexplained neurological symptoms and underscores the continued relevance of portal pyemia from a concealed appendiceal focus. Case Presentation: An 11-year-old Iranian male presented with a three-day history of fever, altered mental status, nausea, and vomiting. Cerebrospinal fluid analysis was normal, and empirical antibiotics were started for suspected meningitis. Abdominal examination revealed only mild diffuse tenderness without peritoneal signs. As symptoms persisted, a non-contrast computed tomography scan of the abdomen was performed on day six of hospitalization, revealing a 49 × 52 × 61 mm subcapsular liver abscess in segment VI with an air-fluid level, adjacent to a thickened appendix containing a 6 mm appendicolith, with localized fat plane obliteration. Laboratory investigations showed marked leukocytosis and elevated alkaline phosphatase, while transaminases remained normal. The patient underwent percutaneous abscess drainage and appendectomy. Abscess cultures grew Escherichia coli, and targeted antibiotic therapy was continued postoperatively. He was discharged with a liver drain, removed ten days after insertion. At one-week follow-up, complete clinical recovery was documented.Conclusions: Pyogenic liver abscess secondary to acute appendicitis, though rare in the modern pediatric population, can still occur and may manifest with misleading extra-abdominal symptoms, such as altered consciousness mimicking central nervous system infection. This case underlines the importance of early abdominal imaging in the septic child without an obvious source. A coordinated multidisciplinary strategy combining source control, image-guided drainage, and pathogen-directed antibiotics leads to excellent outcomes.