Liver abscess

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

K.shirisha

Rollno;68


 A 42 year old male patient occupation by paddy field worker by occupation brought to GM opd on 10/1/23.(2:30pm).with complaints of abdominal pain and fever since 3days 

.shortness of breath since 2 days

Cough since 1 day




History of present illness;


The patient was apparently asymptomatic 3days ago. then he had fever with high grade


which was insidious in onset,  gradually progressive.intermittent in nature and associated with  chills and rigor and evening rise of temperature.


and was relieved on taking by medication which was prescribed by local rmp


C/O pain in right hypochondrium and epigastriumsince 3days.which was sudden in onset and gradually progressive nonradiatingit was dull aching type. No aggrevating and relieving factors. Not relieved on medication


Since on 10/1/23abdominal pain was severe with shortness of breath due to which he visited local rmp .and he was referred to our hospital.


C/O shortness of breath since 2days at rest

No aggrevating and relieving factors

C/Ocough with expectoration , mucoid in consistency

C/Ochest pain associated with cough


C/O loss of appetite since 3days

H/o binge alcohol intake fromJan 1 to Jan 5


No history of vomiting,loose stools,weight loss.,palpitations,pedal edema


No h/O outside food intake

Surgery referral notes:






Past history;


No history of similar complaints inthe past.


he is not a known case of diabetes, hypertension, tuberculosis, asthma and thyroid ,epilepsy disorders



Family history;  insignificant

Personal history:

Appetite: decreased

Diet: mixed

Bowel and bladder: regular

Sleep: adequate

Alcoholic since 2 years

Bidismoker since 20 years

Toddy drinker 


General examination;

Patient is conscious coherent cooperative

Pallor: absent





Icterus: absent



No cyanosis,clubbing, lymphadenopathy, edema




Vitals:

Temp: 100.8f














Bp: 100/70mmhg

HR: 82bpm

RR:20cpm

Spo2: 98%onRa

Grbs: 339mg/dl

systemic examination:

Per Abdomen:




Shape : scaphoid

Umbilicus; central

Movements ; normal

No visible pulsations,or engorged veins,no visible peristalsis

Skin over abdomen ; normal

Palpation : 

Tenderness in right hypochondrium and epigastrium,local rise of temperature present

Hepatomegaly present with span of 15cms

No splenomegaly

Percussion; 

Liver : dull note heared,liver span ;15cms

No shifting dullness or fluid thrills

Auscultation ; bowel sounds are heared


Respiratory system ;

Inspection; 

Inspection of upper respiratory tract;

Oral cavity ; normal

Nose: no dns,polyp

Pharynx; normal

Lower respiratory tract;

Position of apex beat ; left 5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movements of chest ; normal

Position of trachea ; midline

Bilateral air entry present

Palpation:

No tenderness over chest wall,no palpable added sounds,no palpable pleural rub

Percussion;

 Dullnote heared

Auscultation: BAE+

Decreased air entry in RIAA,IMA,ISA

Crepts in heard in RIAA,IMA,IMA

Cardiovascular system;

S1,S2 heared, no murmurs


CNS:

HMF+

No focal neurological deficit


Provisional diagnosis:

Liver abscess . With Right pleural effusion with Denovo type2Dm


Investigations:

10/1/23

Hemogram:

HB: 14.2g/dl

TLC: 34,500

PC: 4.50 lakhs/mm3

Impression: Normocytic normochromic Anemia with leukocytosis

RBS: 375mg/dl

Urine for ketone bodies : negative

RFT:

Blood urea: 46mg/dl

Serum creatinine: 1.1

Na: 135

K: 5.2

Cl: 99

ICA: 0.88

FBS:252

Plbs:

Hba1c:7.1


LFT:

TB: 1.12

DB: 0.50

AST: 18

ALT: 19

ALP: 252

TP: 6.5

Albumin: 3.1

A/G: 0.93

ESR:

100

Mp: negative

Blood for mp strip test: negative


CUE:

Albumin: ++

Sugars: ++++

Pus cells: 4-6

Epithelial cells:3-6


On 16/1/23

Serum amylase:54

Serum lipase: 28

Chest xray



On 13/1/23


USG Abdomen and pelvis


Review USG :
E/O 4.1x4.4cms of well definedhypoechoic lesion noted in  caudate lobe with thickened internal echoes and no septations and vascularity
S/O liver abscess
Pancreas obstructed by gas
Review USG on 16/1/23:



E/O large loculated septated collection noted in pelvis
E/O partially liquified liver abscess noted in caudate lobe of liver
E/O multiple periportal lymphnodes noted
E/O 28x22mm lesion noted in liver in segment 5and 6






ECG:








2d echo:
https://youtu.be/8ww-rdtbidM




Outside reports:









Treatment:

IV fluids NS/RL @ 100 ml/hour

Inj.magnex forte 1.5gm /iv/bd day2

Inj metrogyl 500 mg/iv/Tid

Inj pan 40mg/iv/od

Inj optineuron 1 amp in 100 ml Ns/Bd

Tab. Dolo 650 mg/po/Tid

Inj neomol 1gm/iv/sos ( if temp> 101F)

Inj HAI s/c /Tid according to grbs


11/1/23:


℅ pain in the right hypochondrium, 

℅ sob

No fever spikes


O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:Afebrile 98.7 F

Bp: 110/80 mmHg

HR: 83 BPM

RR:21cpm

Grbs:

8pm: 432mg/dl inj Hai 12u+ 6u nph

10pm: 332 inj 6u hai

12am: 189

2am: 207mg/dl

8am: 287

P/A: soft

Tenderness present in right hypochondrium, in suprapubic region

No guarding rigidity

Bowel sounds: heared

RS: BAE + no crepts

Decreased air entry on Rima, IAA,isa


Cvs: S2,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:

FBS: 252

 S.Urea:41

S creatinine: 0.8

Na: 134

K:5.2

Cl:96

ICa:0.92


Lipid profile:

Cholesterol:118

TG:361

HDL:37.9

LDL:88




A:

Liver abscess with Right pleural effusion

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj.monocef 1gm /iv/bd day2


Inj metrogyl 500 mg/iv/Tid day 2


Inj pan 40mg/iv/od


Inj optineuron 1 amp in 100 ml Ns/Bd


Tab. Dolo 650 mg/po/Tid


Inj neomol 1gm/iv/sos ( if temp> 101F)


Inj HAI s/c /Tid according to grbs





12/1/23

S:℅ pain in the right hypochondrium, 
Fever last night

O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:febrile 100.6f
Bp: 120/90 mmHg
HR: 92BPM
RR:20cpm
Grbs:
8am: 287mg/dl inj Hai 14u+ 10u nph
10am: 198 
12pm: 221mg/dl inj 14u Hai
2pm:107 mg/dl
8pm: 87 inj hai 8u+ 6u nph
10 pm: 127 mg/dl
12am: 89mg/dl
2am: 118mg/dl
8am: 137mg/dl injhai 14u+nph 8u
I/O:3100ml/2000ml
P/A: soft
Tenderness present in right hypochondrium, in suprapubic region
No guarding rigidity
Bowel sounds: heared
RS: BAE + no crepts
Decreased air entry on Rima, IAA,isa

Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit

Investigations:

 S.Urea:41
S creatinine: 0.8
Na: 134-137
K:5.2-4.3
Cl:96-97
ICa:0.92-0.71

Hemogram:
HB:11.4
TLC:20,600
PC:3.9 lakhs



A:
 Liver abscess( hypoechoic) with Right pleural effusion
With Denovo type 2 DM

P:

IV fluids NS/RL @ 100 ml/hour

Inj.monocef 1gm /iv/bd day2

Inj metrogyl 500 mg/iv/Tid day 2

Inj pan 40mg/iv/od

Inj optineuron 1 amp in 100 ml Ns/Bd

Tab. Dolo 650 mg/po/Tid

Inj neomol 1gm/iv/sos ( if temp> 101F)

Inj HAI s/c /Tid according to grbs


https://60shirisha.blogspot.com/2023/01/liver-abscess.html

13/1/23
Amc bed no:5
Unit 2 
Dr.Aashitha sr
Dr .manasa pgy3
Dr. Hari priya , pgy2
Dr. Lohith pgy1
Dr.nithin pgy1
Dr.shirisha intern
Dr.vishal intern
Dr.shirisha intern
:
S
℅ pain in the right hypochondrium, 
Fever last night

O:
Patient was conscious ,coherent, cooperative
Vitals:
Temperature:febrile 102 F
Bp: 110/80 mmHg
HR: 118BPM
RR:20cpm
Grbs:
8am: 137mg/dl inj Hai 14u+ 8u nph
10am: 111
12pm: 107mg/dl 
2pm:99 mg/dl inj hai 2u
4pm: 102
8pm: 112 inj hai 8u+ 6u nph
10 pm: 90mg/dl
2am: 92mg/dl
8am: 124mg/dl injhai 4u+nph 8u
I/O:3500ml/1100ml
P/A: soft
Tenderness present in right hypochondrium, in suprapubic region
Rigidity
No guarding 

Bowel sounds: heared
RS: BAE + no crepts
Decreased air entry on Rima, IAA,isa

Cvs: S1,S2+, no murmurs
CNS: No focal neurological deficit

Investigations:

 S.Urea:41
S creatinine: 0.8
Na: 134-137-138
K:5.2-4.3-4.3
Cl:96-97-97
ICa:0.92-0.71-0.75

Hemogram:
HB:11.4-11.4
TLC:20,600-19900
PC:3.9 lakhs-7.2lakhs



A:
 Liver abscess( hypoechoic) with Right pleural effusion
With Denovo type 2 DM

P:

IV fluids NS/RL @ 100 ml/hour

Inj.monocef 2gm /iv/bd day4

Inj metrogyl 750 mg/iv/Tid day 4

Inj pan 40mg/iv/od

Inj optineuron 1 amp in 100 ml Ns/Bd
Inj Thiamine 200mg in 100 mlNs /iv/Bd
Tab ultracet ½ tab /po/qid
½-½-½-1/2
Inj Tramadol in 100ml ns/iv/bd
Inj Zofer 4mg/iv/tid

Tab. Dolo 650 mg/po/Tid

Inj neomol 1gm/iv/sos ( if temp> 101F)

Inj HAI s/c /Tid according to grbs



https://60shirisha.blogspot.com/2023/01/liver-abscess.html




14/1/23

Amc bed no:5

Unit 2 

Dr.Aashitha sr

Dr .manasa pgy3

Dr. Hari priya , pgy2

Dr. Lohith pgy1

Dr.nithin pgy1

Dr.shirisha intern

Dr.vishal intern

Dr.shirisha intern

:

S

℅ pain in the right hypochondrium, ( resolved)

Fever last night ( relieved)



O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:afebrile 98.6F

Bp: 120/80 mmHg

HR: 88BPM

RR:20cpm

Grbs:

8am: 124mg/dl inj Hai 4u+ 8u nph

10am: 171 

2pm:160mg/dl inj hai 8u

4pm: 165mg/dl

8pm: 132inj hai 8u+ 6u nph

10 pm: 169mg/dl

2am: 127mg/dl

8am: 116mg/dl injhai 8u+nph 6u

I/O:3300ml/1100ml

P/A: soft

 Tenderness in right hypochondrium

No guarding and rigidity


Bowel sounds: heared

RS: BAE + no crepts

Decreased air entry on Rima, IAA,isa


Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:


 S.Urea:41

S creatinine: 0.8

Na: 134-137-138-138

K:5.2-4.3-4.3-4.5

Cl:96-97-97-99

ICa:0.92-0.71-0.75-0.85


Lft:

TB: 1.74

DB:0.42

AST:21

ALT:12

ALP:248

Tp: 5.9

Alb: 2.4

A/G:0.70



Hemogram:

HB:11.4-11.4-11.9

TLC:20,600-19900-21,400

PC:3.9 lakhs-7.2lakhs-4.5lakhs




A:

 Liver abscess( hypoechoic) with Right pleural effusion

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj.monocef 2gm /iv/bd day5


Inj metrogyl 750 mg/iv/Tid day 5


Inj pan 40mg/iv/od


Inj optineuron 1 amp in 100 ml Ns/Bd

Inj Thiamine 200mg in 100 mlNs /iv/Bd

Inj Hai s/c

8u      -8u    -8u

8am. 2pm.  8pm

Inj NPH s/c

6u.    -.   6u

8am.      8pm

Tab. Dolo 650 mg/po/Tid

Inj Tramadol 1 amp in 100lNs/iv/sos


Inj neomol 1gm/iv/sos ( if temp> 101F)


Grbs 7 point profile monitering

Monitor vitals


15/1/23


S

℅  pain in the right hypochondrium, 

Fever since last night



O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:afebrile 98.6F

Bp: 120/80 mmHg

HR: 88BPM

RR:20cpm

Grbs:

8am: 116mg/dl inj Hai 8u+ 6u nph

10am: 122

2pm:118mg/dl inj hai 8u

4pm: 124mg/dl

8pm: 134inj hai 8u+ 6u nph

10 pm: 169mg/dl

2am: 127mg/dl

8am: 104mg/dl injhai 8u+nph 6u

I/O:3300ml/1100ml

P/A: soft

 Tenderness in right hypochondrium

No guarding and rigidity


Bowel sounds: heared

RS: BAE +  crepts in R ISA

Decreased air entry on Rima, 


Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:


 S.Urea:41

S creatinine: 0.8

Na: 134-137-138-138-137

K:5.2-4.3-4.3-4.5-4.2

Cl:96-97-97-99-101

ICa:0.92-0.71-0.75-0.85-0.86


Lft:

TB: 1.74

DB:0.42

AST:21

ALT:12

ALP:248

Tp: 5.9

Alb: 2.4

A/G:0.70



Hemogram:

HB:11.4-11.4-11.9-11.0

TLC:20,600-19900-21,400-24,300

PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs


FBS: 252mg/dl

Plbs: 370mg/dl

Hba1c:7.1%




A:

 Liver abscess( hypoechoic) 

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj.monocef 2gm /iv/bd day6


Inj metrogyl 750 mg/iv/Tid day 6


Inj pan 40mg/iv/od



Inj Thiamine 200mg in 100 mlNs /iv/Bd

Inj Hai s/c

8u      -8u    -8u

8am. 2pm.  8pm

Inj NPH s/c

6u.    -.   6u

8am.      8pm

Tab. Dolo 650 mg/po/sos



Inj neomol 1gm/iv/sos ( if temp> 101F)


Grbs 7 point profile monitering

Monitor vitals


16/1/23

S

℅  pain in the right hypochondrium, ( decreasing)

Fever since last night



O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:afebrile 98.6F

Bp: 110/70 mmHg

HR: 84BPM

RR:20cpm

Grbs:

8am: 104mg/dl inj Hai 8u+ 6u nph

10am: 210

2pm:226mg/dl inj hai 8u

4pm: 124mg/dl

8pm: 92inj hai 8u+ 6u nph

10 pm: 169mg/dl

2am: 230mg/dl

8am: 102mg/dl injhai 8u+nph 6u

I/O:3500ml/1000ml

P/A: soft

 Tenderness in right hypochondrium

No guarding and rigidity


Bowel sounds: heared

RS: BAE +  crepts in R ISA

Decreased air entry on Rima, 


Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:


 S.Urea:41

S creatinine: 0.8

Na: 134-137-138-138-137

K:5.2-4.3-4.3-4.5-4.2

Cl:96-97-97-99-101

ICa:0.92-0.71-0.75-0.85-0.86


Lft:

TB: 1.74

DB:0.42

AST:21

ALT:12

ALP:248

Tp: 5.9

Alb: 2.4

A/G:0.70



Hemogram:

HB:11.4-11.4-11.9-11.0-10.9

TLC:20,600-19900-21,400-24,300-19,400

PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs


FBS: 252mg/dl

Plbs: 370mg/dl

Hba1c:7.1%




A:

 Liver abscess( hypoechoic) 

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj. Piptaz 4.5 gm /iv/Tid d2


Inj metrogyl 750 mg/iv/Tid day 7


Inj pan 40mg/iv/od



Inj Thiamine 200mg in 100 mlNs /iv/Bd

Inj Hai s/c

8u      -8u    -8u

8am. 2pm.  8pm

Inj NPH s/c

6u.    -.   6u

8am.      8pm

Tab. Dolo 650 mg/po/sos



Inj neomol 1gm/iv/sos ( if temp> 101F)


Grbs 7 point profile monitering

Monitor vitals



On 17/1/23


℅  pain in the right hypochondrium, suprapubic region ( decreasing)

Fever since last night



O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:febrile 101.8f

Bp: 120/70mmHg

HR: 84BPM

RR:20cpm

Grbs:

8am: 162mg/dl inj Hai 8u+ 6u nph

10am: 210

12pm:164mg/dl inj hai 8u

2pm: 85mg/dl

4pm:165mg/dl

8pm: 112inj hai 8u+ 6u nph

10 pm: 131mg/dl

2am: 148mg/dl

8am: 137mg/dl injhai 8u+nph 6u

I/O:3100ml/1250ml

P/A: soft

 Non tender

No guarding and rigidity


Bowel sounds: heared

RS: BAE +  crepts in R ISA

Decreased air entry on Rima, 


Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:


 S.Urea:41-13

S creatinine: 0.8-0.9

Na: 134-137-138-138-137-134

K:5.2-4.3-4.3-4.5-4.2-4.6

Cl:96-97-97-99-101-98

ICa:0.92-0.71-0.75-0.85-0.86


Lft:

TB: 1.74

DB:0.42

AST:21

ALT:12

ALP:248

Tp: 5.9

Alb: 2.4

A/G:0.70



Hemogram:

HB:11.4-11.4-11.9-11.0-10.9-8.5

TLC:20,600-19900-21,400-24,300-19,400-17k

PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs-7 lakhs


FBS: 252mg/dl

Plbs: 370mg/dl

Hba1c:7.1%




A:

 Liver abscess( hypoechoic) 

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj. Piptaz 4.5 gm /iv/Tid d3


Inj metrogyl 750 mg/iv/Tid day 8


Inj pan 40mg/iv/od



Inj Thiamine 200mg in 100 mlNs /iv/Bd

Inj Hai s/c

8u      -8u    -8u

8am. 2pm.  8pm

Inj NPH s/c

6u.    -.   6u

8am.      8pm

Tab. Dolo 650 mg/po/sos



Inj neomol 1gm/iv/sos ( if temp> 101F)


Grbs 7 point profile monitering

Monitor vitals


18/1/23

℅  pain in the right hypochondrium, suprapubic region ( decreasing)

Fever since last night



O:

Patient was conscious ,coherent, cooperative

Vitals:

Temperature:febrile 101.8f

Bp: 120/70mmHg

HR: 84BPM

RR:20cpm

Grbs:

8am: 137mg/dl inj Hai 8u+ 6u nph

10am: 232

12pm:164mg/dl inj hai 8u

2pm: 139mg/dl

4pm:165mg/dl

8pm: 114inj hai 8u+ 6u nph

10 pm: 114mg/dl

2am: 309mg/dl

8am: 115mg/dl injhai 8u+nph 6u

I/O:3800ml/1550ml

P/A: soft

 Non tender

No guarding and rigidity


Bowel sounds: heared

RS: BAE +  

Decreased air entry on Rima, 


Cvs: S1,S2+, no murmurs

CNS: No focal neurological deficit


Investigations:


 S.Urea:41-13

S creatinine: 0.8-0.9

Na: 134-137-138-138-137-134

K:5.2-4.3-4.3-4.5-4.2-4.6

Cl:96-97-97-99-101-98

ICa:0.92-0.71-0.75-0.85-0.86


Lft:

TB: 1.74

DB:0.42

AST:21

ALT:12

ALP:248

Tp: 5.9

Alb: 2.4

A/G:0.70



Hemogram:

HB:11.4-11.4-11.9-11.0-10.9-8.5-10

TLC:20,600-19900-21,400-24,300-19,400-17k-17600

PC:3.9 lakhs-7.2lakhs-4.5lakhs-5.2 lakhs-5.71 lakhs-7 lakhs-6.2lakhs


FBS: 252mg/dl

Plbs: 370mg/dl

Hba1c:7.1%




A:

 Liver abscess( hypoechoic) 

With Denovo type 2 DM


P:


IV fluids NS/RL @ 100 ml/hour


Inj. Piperacillin + Tazobactem 4.5 gm /iv/Tid d4



Inj pantoprazole 40mg/iv/od



Inj Thiamine 200mg in 100 mlNs /iv/Bd

Inj Hai s/c

8u      -8u    -8u

8am. 2pm.  8pm

Inj NPH s/c

6u.    -.   6u

8am.      8pm

Tab. Paracetamol 650 mg/po/sos



Inj paracetamol 1gm/iv/sos ( if temp> 101F)


Grbs 7 point profile monitering

Monitor vitals


Brief course in the hospital:


Day-1: patient presented to the opd with pain in right hypochondrium and high grade fever , cough, and shortness of breath and the grbs was 339 at the time of presentation and was kept on iv antibiotics for hiS fever and inj huam. Actrapid insulin started as his sugat levels were high and. Ultrasound abdomen was done and it showed well defined heteroechoic cystic lesion With no internal vascularity in left lobe of liver and liver abscess was found on ultrasound and inj metronidazole was started and as he is alcoholic inj Thiamine was started


Day-2: pain abdomen and fever weren't subsided and continued on same antibiotics and review USG was done for liver abscess and it showed a 4.2x 4.1 cms well defined hypoechoic lesion noted in cauadate lobe of liver

With thick internal echoes and no vascularity and surgery consultation was taken and advised pig tail catheter drainage once the abscess was liquified and serum amylase,lipase were send and are normal

Day-3: As the patient sob is not relieved and repeat chest x ray was done and it showed with CLEAR lung fieldsand USG chest was done and it showed b/l. Mild pleural effusion

Day-4: pain in the right hypochondrium decreasing and no fever spikes were present and there is a mild tendeness in right hypochondrium

Day-5: pain in hypochondrium decreased and no fever spikes were present.tendernessin right hypochondrium decreasing and blood and urine cultures has no growth

Day 6: Review abdomen was done it was found to be having 4.1x4.0 cms hypoechoic lesion noted in cauadate lobe of liver with greater than 60% liquefaction

And no vascularity and 22x28mm hypoechoic lesion noted in 5and 6 segment of liver with no vascularity and loculated ascitis.

Day-7:

Review surgery opinion was taken for liver abscess and advised serum amylase, lipase and are normal and advised to continue the same treatment

Day-8: As his fever got subsided and pain abdomen got relieved and hai sugar levels were under controlAnd the injectable firm of insulin was converted into oral hypoglycemic agents and the rest symptomatic treatment was continues

Day-9: pateint is hemodynamically stabel and the patient is get discharged with HB: 10.4,Tlc:16,400,platelet count:

5.7 lakhs

Conclusion:

.Liver abscess is a potentially life threatening disease and commonly associated with underlying gastrointestinal pathology

Clinical features:

Pain in right upper quadrants, vomitings,high grade fever, with chills and rigor, loose stools,sob

Treatment:

Adequate antibiotic coverage and image guided intervention is optimal first-line treatment with favorable outcome.


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