Background: Despite belonging to the oropharynx commensal flora, gastrointestinal tract and female genital tract, in rare cases Actinomyces species may cause actinomycosis, characterized by abscesses formation in the lungs or gastrointestinal tract, usually in immunocompromised patients and in association with other infectious agents. Although cervicofacial infections are the most often seen form of the disease, hepatic localization appears in 15% of patients with abdominal symptoms. We describe a case of hepatic abscess in an immunocompetent female who came with an unusual presentation and no others signs of liver suffering.
Case report: 73 year old female on chronic treatment for high blood pressure and dislipidemia went to a neurologist accusing dyplopia and asthenia. Clinical exam was normal, except sixth cranial nerve paresis; common laboratory investigations and a cerebral MRI were performed, showing no relevant changes. Three days later, the patient needed urgent hospital admission for septic shock, fever, shortness of breathing and hematological disturbances. Lab investigations showed leukocytosis (19200/mm3), thrombocytopenia (45000/mm3), anaemia, slight elevation of hepatic enzymes and  elevated levels of presepsine (1880pg/ml) and CRP  (258 mg/l). A thoracic and abdominal CT examinations revealed bilateral pleural effusions, hepatomegaly with diffuse steatosis and a solid mass of 5 cm/2.8 cm from polycystical aspect situated in the third hepatic segment, which rise the suspicion of a hepatic abscess. Blood culture grew Actinomyces odontolyticus and Streptococcus intermedius and the patients received high doses of penicillin G iv (24 million units/day), followed by oral therapy with doxycycline and amoxicilin. A new CT exam showed increasing of the hepatic lesions at 7.5 cm/4.5 cm with an evident aspect of a hepatic abscess. After the attempt of abscess drainage under ultrasound guidance and lavage with saline, a subcapsular hematoma has developed on the visceral margin of the left hepatic lobe. The pus obtained from puncture confirmed the same agents found in blood cultures. After 2 months of antibiotic therapy, complete resolution of the abscess was obtained and also significant reduction in size of the subcapsular hematoma, as documented by the MRI examination . 
Discussion and conclusions: this case is particular in the peculiar onset of the disease in a immunocompetent patient with no abdominal symptoms or initial sepsis signs. Although the majority of these cases end up needing surgical drainage, in our patient, percutaneous drainage was complicated with a subcapsular hematoma. The successful conservative management of this case with prolonged antiobiotherapy was due to close interdisciplinary collaboration between infectionist, microbiologist, surgeon, gastroenterologist  and intensivist.

Diagnostic challenges in a case of hepatic abscess with Actinomyces odontolyticus and Streptococcus intermedius