Discussion
Pyogenic liver abscesses represent one of the rarer, but potentially life-threatening diseases of the liver.[1, 12, 17] In their randomised trial, Lee et al. showed that particular predictors for protracted hospital admissions were: diabetes mellitus; arterial hypertension; positive identification of bacteria in culture; and reduced Hb values at the time of diagnosis Independent risk factors identified as part of the trial also included an abscess diameter of >5 cm, and a significantly elevated CRP.[15] If these factors were to be considered for the case we have presented here, then the initially poor prognosis for our case would have been associated with an indication for an in-patient hospital stay >14 days as well as surgical treatment of the liver abscess with percutaneous drainage.[9, 18] There are no data that recommend or consider purely conservative therapy possible for large or multifocal liver abscesses. All current data show that without doubt good therapy of all risk factors, such as diabetes mellitus, is crucial for the prognosis of the disease.[19-22] This also applies to the case described here. However, the optimal therapy for diabetes mellitus can only be achieved through the cooperation of the patient and the close supervision by the GP´s. This is also possible via telemedical offers.[23, 24] There has been no known use of telemedicine with respect to treatment monitoring for acute diseases of the liver. Experience has been described, however, of telemedicine approaches used in hepatology for the treatment and monitoring of patients with chronic liver disease, or following liver transplant.[24, 25] The 2020/2021 coronavirus pandemic has particularly broadened the application of telemedicine initiatives.[26] There is also a long tradition of telemedicine applied to the treatment of diabetes mellitus: experience has shown that telemedicine care applied to all forms of diabetes mellitus (types 1-3 and gestational diabetes) is qualitatively equal to regular care under a specialist, and can lead to good or very good long-term outcomes.[27, 28] In particular, continued surveillance of patients via telemedicine visits increases patient compliance in all cases. This has a significant impact on treatment success, and certainly would have contributed to the outcome in the case presented by us here.
Our case also demonstrates how even rather banal irritations, such as over-zealous cleaning of teeth, may be sufficient to cause liver abscess in patients with untreated risk factors. This hypothesis is further reinforced by the fact that we isolated a typical organism in this respect: Streptococcus intermedius . The literature also describes case reports in this context for patients who had no known risk factors.[16]
Finally, our case report has shown how precise ultrasound follow-up of inflammatory liver lesions can be when using CEUS. The ultrasound imaging showed a good correlation with results from CT scans of the liver. (fig.:1) Furthermore, the regression of the lesion is a good indicator for evaluation of the effectiveness of medication-based anti-inflammatory treatments.[29] This is also in line with the recommendations of the current guidelines for CEUS.[30] CEUS is quick, easy-to-use, and is associated with very few side effects. As such, we would particularly like to encourage general practitioners to start using CEUS for specific indications as part of their portfolio of diagnostic tools.