conflict of interest : the authors declare no conflict of interest . dedication : this article is dedicated to the hard - working faculty of wayne state university internal medicine residency program for their commitment to educate and support the residents . . however , they are the most common cause of visceral abscesses with a median age of just under 60 years and preponderance towards the male sex . the mechanism by which these abscesses form seems to be by entry through the portal circulation or biliary tract , though hematogenous spread is also possible . the most commonly implicated organisms are klebsiella species , escherichia coli and the enterococus species . risk factors associated with increased incidence of liver absceses include diabetes mellitus , hepatobiliary and pancreatic disease , and liver transplantation . fusobacterium necrophorum causing liver abscesses is a rare disease and only a few cases have been reported . we present a case of liver abscesses in an immunocompetent elderly female with past medical history of diverticulosis , copd , hypertension , and hysterectomy . an 88-year - old female presented to her primary care physician with one week of fevers , night sweats , chills , fatigue and vague right upper quadrant abdominal pain . a computed tomography ( ct ) scan of the abdomen was performed , showing two liver abscesses in the right lobe as well as extensive diverticulosis as seen in figure 1 . percutaneous drainage was performed and a draining catheter was placed in the larger abscess as seen in figure 2 . it showed an increase in size of the second abscess , necessitating a second percutaneous drainage and a draining catheter to be inserted . she was subsequently discharged with a picc line for antibiotics at home and drains remained in place for abscess drainage . fusobacterium necrophorum is a non - motile gram - negative anaerobic bacillus that is present in the oropharynx and gastrointestinal tract . the source of infection described in reported cases include hematogenous spread from dental caries / peritonsillar abscess and those involving the gi tract resulting from inflammation of the bowel wall or from inflamed diverticuli via the portal circulation . in a published case review , two of these cases had diverticular disease with the co - existence of diabetes mellitus - a known risk factor for liver abscess formation . our patient had severe diverticular disease as per ct scan , which is likely the source of infection as no other sources could be identified . . a typical feature would be the double target sign , which is where a hypoattenuating central lesion is surrounded by an enhancing rim in computed tomography with contrast . the differential radiologic diagnoses can include metastases from malignancies ( specifically necrotic metastases ) , liver cysts , bilirary cystadenoma , hepatic hemangioma and hepatic infarct . metastatic lesions tend to lack the double target sign and do not contain gas , but may have calcifications . cystic lesions in the liver tend to have a homogenous hypoattentuation and an indistinguishable wall that does not enhance with contrast . although hypoattenuating , hemangiomas on the other hand show hyperattenuation in the delayed phase , where contrast fills these vascular lesions . hepatic infarction , in comparison , tends to be vaguely defined lesions that are usually peripheral and have a wedge appearance . in the cases reviewed , treatment duration ranged from 3 - 12 weeks . the two liver abscesses in which patients had an underlying diverticular disease were treated for 8 and 12 weeks respectively . the recommended course of treatment of pyogenic liver abscesses is 4 - 6 weeks ; however , no randomized trials exist to describe optimal duration of therapy . f. necrophorum isolates are usually sensitive to treatment with metronidazole , with 2% resistance to penicillin and 15% to erythromycin . the majority of the published cases combined metronidazole with another broadspectrum antibiotic with gram - negative coverage . these have included ciprofloxacin , cefriaxone , ampicillin / clavulanic acid , tazobactam / piperacillin and meropenem . eight of 13 cases required drainage of the abscess in addition to the antibiotic therapy , though no mention was made regarding the reason to do so . it is essential that both aerobic as well as anaerobic abscess fluid cultures are performed since fusobacterium is an anaerobe . the importance of this is because these organisms are highly sensitive to metrinidazole as stated above . it should , however , be considered in the differential diagnosis as it is highly sensitive to antibiotic treatment . the source of infection may not always be identified , but oropharyngeal and gi tract infections should be considered .
liver abscesses are an uncommon disease that can present with vague symptoms . fusobacterium necrophorum causing liver abscesses 
 is a rare condition and only a few cases have been reported . 
 an 88-year - old female presented to her primary care physician with one week of fevers , night sweats , chills , fatigue and vague right upper quadrant abdominal pain . 
 she denied nausea , vomiting , constipation , diarrhea and unintentional weight loss . 
 a computed tomography scan of the abdomen showed two liver abscesses in the right lobe as well as extensive diverticulosis . 
 percutaneous drainage was performed and draining catheters were placed in the abscesses . 
 culture of the abscess fluid grew fusobacterium necrophorum . 
 she was treated with ceftriaxone and metronidazole as per sensitivities . 
 rare cases of f. necrophorum hepatic abscesses have been published . 
 the source of infection described in reported cases included hematogenous spread from dental caries / peritonsillar abscess and those involving the gastrointestinal tract resulting from inflammation of the bowel wall or from inflamed diverticuli via the portal circulation . in one study , 
 thirteen cases of liver abscess due to f. necrophorum were studied , and two of these cases had diverticular disease without inflammation .