Case history
A 67-year-old physician with a past history of hypertension, allergic rhinitis and hepatic hemagioma for 10 years received the first dose of ChAdOx1nCov-19 vaccine on 2021/3/22. Three days later, he presented with fever, up to 39oC, combined with general soreness. He took an acetaminophen tablet and his fever subsided completely. However, fever up 39.3℃ with chills occurred on 3/31, and he was admitted for detailed evaluation. Blood culture was done. Neither leukocytosis nor a higher C-reactive protein (CRP) level was noted, and the Covid-19 PCR was negative. The next day, his fever subsided and he was discharged.
However, he developed a fever, up to 38.5℃, 2 days after discharge. Owing to persistent fever for 3 days, he subsequently visited the infectious disease outpatient department and was admitted for further evaluation. On admission, he had a temperature of 37.6℃, blood pressure of 127/71 mmHg, and heart rate of 80 beats per minute. On physical examination, he did not have a toxic appearance, but his tonsils had erythematous enlargement. No neck lymphadenopathy was found. His chest examination revealed clear breathing sounds, and a regular heart rhythm without murmur. His abdominal examination revealed a soft abdomen without rigidity or rebound, and no tenderness to palpation. There was no lower extremity edema. His skin was intact without rashes. His white blood cell count was 20.14×103/μL (reference range 3.8–10.8×103/μL) with 86.8% neutrophils, hemoglobin was 12.9 g/dL (reference range 12–15.5 g/dL), and platelet count was 246×103/μL (reference range 150–450×103/μL). His liver chemistries revealed aspartate aminotransferase of 50 U/L, alanine aminotransferase of 60 U/L, and total bilirubin of 0.64 mg/dL. Meanwhile, a CRP level of 148.56 mg/L (reference range <5 mg/L) and procalcitonin C of 3.1 ng/ml (reference range <0.5 ng/mL) were found, which revealed his inflammatory markers were significantly more elevated than during the previous admission. His COVID-19 nasopharyngeal swab test was still negative. Both abdominal echography and computed tomography of the abdomen showed 4.5-cm abscesses at left lateral segment of the liver (Figure 1). Blood cultures were obtained and he was given empiric antibiotic treatment. The liver abscess was drained with a pigtail catheter on the next day. The pus smear revealed Gram-negative bacilli. Later, his blood cultures, which had been collected during the previous admission, yieldedFusobacterium nucleatum (F. nucleatum ). He then underwent a colonoscopy examination, which revealed diverticulosis at the cecum and ascending colon. A dentist was consulted and asymptomatic periodontitis was found.
The patient then received antibiotics with metronidazole and underwent liver abscess drainage. His fever subsided completely and he was discharged under a stable status. After 4 weeks of metronidazole treatment, the patient was able to return to his normal daily life.