Background <p>Granulomatosis of the liver may present a diagnostic enigma. Granulomas are organized aggregates of macrophages that form as a chronic inflammatory response to various stimuli.</p> Case presentation <p>We report a case of a 69-year-old white male patient presenting with fever and lower extremity pain but no other symptoms of infection. Despite extensive diagnostic evaluations, no infectious source was identified. Initial empirical antibiotic therapy failed, prompting treatment with methylprednisolone and methotrexate, which improved clinical and laboratory parameters. Subsequent imaging revealed multiple hepatic lesions, and histopathology indicated granulomatous lesions with central necrosis suggestive of tuberculosis, although no mycobacterial genetic material was found. Further infectious and systemic disease testing remained inconclusive. The patient was diagnosed with idiopathic granulomatous hepatitis and remains asymptomatic with no disease progression.</p> Conclusion <p>This case highlights the diagnostic challenges and management of hepatic granulomas of undetermined etiology and fever of unknown origin.</p>