Case Presentation: A 58-year-old male with a history of alcohol use disorder, recurrent diverticulitis, and portal vein thrombosis presented to the ED due to jaundice and tremors. He reported malaise, poor oral intake, fevers, and night sweats. Denied weight loss. A telehealth visit prescribed Motrin and Tylenol. The patient consumes 1 liter of vodka weekly, with the last drink the day before admission. He has a history of alcohol withdrawal and a normal colonoscopy 5-6 years ago.ED vitals: elevated BP 207/125, tachycardia 120, RR 18, Temp 98.4. Elevated WBCs 22, low Hgb 10.6, and decreased platelets 68. CMP: elevated creatinine 1.65, low sodium 125, low potassium 2.7, abnormal LFTs (AST 253, ALT 159, ALP 709) and elevated ammonia level 553. CT revealed suspicious hepatic masses and colonic fat stranding, prompting admission for further investigation.Consultations included Academic Surgery, Gastroenterology, and Hematology/Oncology. Tumor markers CA 125 (42 unit/mL) and CA 19-9 (411 unit/mL) were elevated, prompting suspicion of metastatic cancer. However, subsequent investigations, including ultrasound, blood tests, and biopsies, revealed colonic contained abscess/perforation secondary to diverticulitis.The patient underwent drainage, and liver abscess was confirmed via biopsy with culture revealing strep intermedius. The elevated tumor markers were attributed to the inflammatory response. The patient was discharged with 3 drains, antibiotics, PPIs, and follow-up appointments with GI, Surgery, and Hematology specialists. Alcohol cessation was strongly advised.
Discussion: Hepatic abscesses have several etiologies including biliary disease, liver transplantation, abdominal surgery, trauma and infection. Uncommonly they can also be a complication of diverticulitis via the portal venous route. Despite tumor markers being valuable in malignancy diagnosis, elevated levels can complicate distinguishing benign from malignant conditions. For example, CA 19–9, a GI cancer-associated antigen, is expressed in both cancer cells and normal epithelial tissues. CA 125 exhibits elevated levels in neoplasms like ovarian, breast, and lung carcinoma, as well as in non-neoplastic conditions such as endometriosis and end-stage liver disease. Our case describes a 58-year-old male with a history of alcohol use disorder who was admitted for generalized weakness, jaundice, and elevated tumor markers CA 125 and CA 19-9. Despite a benign final diagnosis of diverticulitis, the case highlights the diagnostic challenge posed by elevated tumor markers in non-malignant conditions.This presented case is a suitable topic for a hospital-based medicine forum due to its intricate nature and relevance to inpatient care. This case required multi-system coordination among various medical specialties, emphasizing the collaborative focus of hospital-based care.The diagnostic decisions made during the inpatient stay present educational value and gives insight into the challenges of managing liver abscesses, diverticulitis complications, and elevated tumor markers.
Conclusions: This case emphasizes the need for a balanced consideration of non-malignant differentials when evaluating patients with elevated tumor markers. It also serves as a reminder to avoid malignancy biases, especially in patients within a susceptible age range, guiding a thoughtful diagnostic approach to avoid unnecessary procedures and enable targeted management.