Background: Pyogenic liver abscess (PLA) is an uncommon but potentially life-threatening cause of sepsis. Klebsiella pneumoniae is increasingly recognised as a dominant pathogen worldwide. Diagnostic delay is common, particularly when hepatic lesions have atypical radiological features or coexist with alternative intra-abdominal pathology. Differentiating PLA from parasitic cystic disease remains a key challenge in hepatobiliary practice. Case: A 49 year old male presented with sepsis, urinary symptoms and lower abdominal pain. CT imaging demonstrated uncomplicated acute appendicitis and two incidental multiloculated cystic liver lesions, radiologically favoured to represent hydatid disease. Laparoscopic appendicectomy was performed; however, the patient remained persistently febrile despite appropriate antimicrobial therapy. Further hepatobiliary imaging with ultrasound and contrast-enhanced MRI demonstrated thin-walled multiloculated lesions with septations and diffusion restriction, raising concern for multifocal PLA despite overlapping features with hydatid disease. A concurrent Klebsiella pneumoniae urinary tract infection was identified. In the setting of ongoing sepsis, multidisciplinary consensus supported image-guided aspiration. Percutaneous drainage yielded purulent material; while cultures were negative, broad-range 16S rRNA PCR confirmed Klebsiella pneumoniae. Following drainage and targeted antimicrobial therapy, the patient made a sustained clinical recovery. Conclusion: This case highlights the limitations of imaging alone in characterising complex hepatic cystic lesions. Persistent sepsis despite definitive treatment of appendicitis should prompt reconsideration of alternative or concurrent sources of infection, in this case hepatobiliary reassessment and evaluation for occult hepatic infection. Imaging guided aspiration can provide both diagnostic certainty and definitive source control, even when parasitic disease remains a competing differential.