A 12-year-old boy was first seen in May 2003 for a tympanoplasty, when a peri-operative chest radiograph showed a calcified granuloma in the right lung (Figs 1a and 1b), but no other abnormality. In September 2003 he was seen again, referred by his rural general practitioner, with a 3-week history of right upper quadrant pain, fever, anorexia and weight loss. He had had a non-productive cough for a week, was pyrexial (37.8°C) and tachypnoeic, with dullness to percussion and decreased breath sounds at the right pulmonary base. He had marked right upper quadrant abdominal tenderness with guarding and a 3 cm hepar, but was not jaundiced. His white cell count was 14.9 x 109 /ml and his erythrocyte sedimentation rate (ESR) 140 mm/hour. Chest radiography revealed a markedly elevated right hemidiaphragm, with loss of clarity in its mid-portion and some right fissural thickening (Figs 2a and 2b). An ultrasound examination showed three mixed echogenicity liver lesions interpreted as abscesses (Fig. 3). One was located in the left lobe (6 cm diameter), and two were in the right lobe, measuring approximately 8 cm and 10 cm in diameter respectively. The abscess in segments 7 - 8 showed transdiaphragmatic rupture into the right pleural space (Fig. 4). During respiratory excursion, ultrasound showed abscess contents moving across this defect. A contrast-enhanced computed tomography (CT) scan of the liver (Figs 5a and 5b) showed thick fluid and septations in the lesion in segments 7 - 8, while homogeneous thick fluid was demonstrated in the other two. The presence of septations in one of the cysts raised the possibility of complicated hydatid disease
