Culture-Negative Pyogenic Liver Abscess Presenting as Lung Abscess and Empyema Through Transdiaphragmatic Spread

A woman in her 40s presented with progressive dyspnoea and cough, preceded by anorexia and significant weight loss. Initial chest radiography showed apparent elevation of the right hemidiaphragm with right lower zone opacification, raising concern for thoracic or intra-abdominal malignancy. Laboratory investigations revealed severe normocytic anaemia, leucocytosis, hypoalbuminaemia and elevated alkaline phosphatase. Contrast-enhanced CT demonstrated a large subcapsular right hepatic abscess with contiguous transdiaphragmatic extension into the right lower thorax, complicated by lung abscess and pleural empyema. Blood and liver abscess cultures were negative; the liver aspirate was obtained after 7 days of antimicrobial therapy. She was treated with antimicrobial therapy and image-guided liver abscess drainage, achieving sustained clinical and biochemical recovery, with ultrasonographic resolution of the hepatic collection. This case highlights the importance of considering a subdiaphragmatic source in patients presenting with lung abscess or empyema adjacent to the right hemidiaphragm.