What is diagnosis

A 65-year-old male with a past history of cigarette smoking and asbestos exposure (in the 1970s) presented to the emergency department with a one-month history of progressive dyspnea, right-sided pleuritic chest pain, cough productive of white-coloured sputum and malaise. His health problems had commenced four months before presentation while he was vacationing at a northern Ontario resort. At that time, he had felt unwell and had developed a fever with rightsided pleuritic chest pain that radiated to his right shoulder. The diagnosis was an upper respiratory tract infection, made by the local physician; the patient was treated with a 10-day course of cephalexin. Although his condition had initially improved after the antibiotic therapy, during the month before presentation he had experienced increasing fatigue, cough with clear sputum production and a loss of appetite. He also developed worsening right-sided pleuritic chest pain that radiated to the right shoulder, dyspnea and orthopnea. He had no nausea, vomiting, diarrhea or hemoptysis. However, he had lost 4 kg and had drenching night sweats over the previous three and a half months. Further history revealed that he had drunk well water during his vacation in northern Ontario and that several families who were with him at that time also became ill, although he was not aware of the nature of their symptoms.
On examination, he was a thin male in some respiratory distress and was afebrile. His blood pressure was 140/90 mmHg, and he had a heart rate of 80 beats/min and a respiratory rate of 30 breaths/min. Chest examination revealed percussion dullness, decreased breath sounds, crackles, and bronchial breathing in the right base and mid-lung fields. No clubbing was observed. There was no jugular venous distention, and heart sounds were normal without any murmurs. His abdomen was flat, but he had mild right upper quadrant tenderness on deep palpation. No abdominal masses were palpable, no organomegaly was appreciated and there were no stigmata of chronic liver disease. Bowel sounds were present.
The patient's oxygen saturation was 89% on room air. The white blood cell count revealed mild leukocytosis of 12.2x109/L without a left shift, but hemoglobin and platelet counts were normal. The erythrocyte sedimentation rate was 38 mm/h. The level of serum aspartate aminotransferase was 28 U/L, while the alanine aminotransferase level was mildly elevated at 47 U/L; the alkaline phosphatase and gammaglutamyl transpeptidase levels were moderately elevated at 380 U/L and 243 U/L, respectively. The patient's total bilirubin concentration was normal, but the albumin concentration was depressed at 32 g/L. All other serum chemistry values were within normal limits.

A chest x-ray (Figure 1) showed a large right pleural effusion with associated
consolidation or subsegmental atelectasis in the right middle and lower lung zones. An underlying parenchymal mass could not be excluded. Computed tomography of the thorax with contrast enhancement (Figure 2) revealed no masses in the lung
parenchyma or the mediastinum. However, it demonstrated a 10 cm fluid collection occupying most of the right lobe of the liver, with peripheral enhancement consistent with a massive liver abscess.
                                   Figure 1.

                                      Figure 2

Percutaneous computed tomography-guided drainage of the liver abscess ensued, and 200 mL of bloody purulent fluid was aspirated. In addition, a chest tube was inserted, and 900 mL of fluid of similar consistency with numerous leukocytes was removed from the thorax. Microscopic examination of the fluids did not reveal any microorganisms, and cultures of the fluids and blood were negative for bacteria. Thereafter, therapy consisting of intravenous clindamycin 600 mg every 8 h and oral ciprofloxacin 750 mg bid was initiated.
What is your diagnosis?