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.