Pyogenic liver abscess is a potentially life threatening illness. The diagnosis in older adults may be a challenge because of the nonspecific clinical presentation. This letter describes a case of a 74-year-old man who presented with hypotension, a recent fall, delirium, and a high white blood cell count of unknown etiology. The diagnosis was made with the help of imaging and biopsy. The causative bacteria were unknown. There was no malignancy. He eventually needed drainage of his abscess in spite of being treated with antibiotics.