Case
A 50-year-old male patient was referred to our clinic with the diagnosis
of “liver tumour of unclear type”. On examination the patient was
obese (115kg; 187cm; BMI: 32.9), and had presented to the doctor due to
a deterioration in his condition. He reported complaints of 12 kg weight
loss over the previous 4 weeks as well as increasing physical weakness
and joint complaints. The patient had recorded fever spikes recurring in
the evening approximately every 5 days, reaching up to 39°C. The general
doctor treating the patient (his general practitioner) identified a
large tumour-like structure in the liver on a diagnostic ultrasound
scan, and referred the patient to the clinic.
The admission report from the clinic describes an oriented patient in a
poor general condition and with obese nutritional status. Clinically,
pulmonary findings were normal with vesicular breathing sounds. No
dyspnoea; no cyanosis. Heart sounds were clear with no extra sounds.
Abdomen was soft with no pain on percussion or deep palpation. No
visible changes to the skin, and no jaundice. No abnormalities found on
palpation of the abdominal wall, but obesity was noted. Pains in the
area of the right shoulder. With the exception of arterial hypertension
and obstructive sleep apnoea syndrome, the patient denied any prior
medical history. The patient denied taking any regular medication.
Laboratory analysis showed leucocytosis of 13.3 /nl (4-9 /nl). Further
results were recorded: D-dimer value of 3.31 mg/l FEU (<0.55
mg/l FEU); ferritin of 1.853 ng/ml (21-360 ng/ml); and CRP of 18.8 mg/dl
(<0.5 mg/dl) A case of normochromic normocytic anaemia was
identified, with a Hb value of 12 g/dl (14-18 g/dl). Serum glucose
levels were recorded at 276 mg/dl (70-115 mg/dl); HbA1c was 93 mmol/mol
Hb (20-42 mmol/mol Hb). (Tab.:1)
A thoracic x-ray did not reveal any abnormalities. Ultrasound of the
liver showed a polycystic liver lesion in the left lobe measuring
approx. 7 cm in diameter. A further liver lesion located close to the
capsule and measuring approx. 3 cm in diameter could be demarcated in
liver segment IV. Both lesions appeared on contrast-enhanced ultrasound
scan (CEUS) as typical augmented ring enhancements in the arterial phase
with a drop in contrast signal in the centre of the lesion. In the
portal-venous and late phases, the lesion borders again appeared
hyperechoic-to-isoechogenic with a consistent lack of contrast signal
within the lesion (Fig.:1). This contrast pattern is typical of a liver
abscess. The findings were confirmed using triphasic, contrast-enhanced
CT: description of the CT imaging included a polycystic liver lesion in
the left lobe measuring 68 mm in diameter, and a liver lesion (segment
IV) measuring 25 mm in diameter, with a suspected finding of liver
abscesses. (fig.:1)
The liver lesion in the left lobe was selected as the reference lesion
for assessment during follow-up.
Diagnostic testing in microbiology showed evidence ofStreptococcus intermedius in both peripheral blood cultures and
from the lesion itself. Resistance testing showed that the strain
isolated was sensitive to all standard antibiotic agents.
We arrived at the summary diagnosis of a multifocal pyogenic liver
abscess with evidence of Streptococcus intermedius in a patient
suffering from type-2 diabetes mellitus.
Due to evidence of Streptococcus intermedius as the causative
pathogen for this pyogenic liver abscess, extensive diagnostic testing
was carried out to localise any potential source (gastroscopy,
colonoscopy, dental and ENT examination). In summary, no source for the
infection could be found. The only potential source for infection which
could be identified by us on the basis of the available literature was
the use of interdental brushes by the patient which he reported as part
of his routine dental care.[16]
The treatment regime focused on two areas: antibiotic treatment for the
pyogenic liver abscess; and optimisation of the diabetes-related
metabolic condition in this patient with type-2 diabetes mellitus.
Following results from the resistogram, intravenous antibiotic treatment
was initially started with ampicillin/sulbactam (6 g/3 g daily) for 5
days.
The type-2 diabetes mellitus was treated during the acute phase of the
illness (days 0-5) using insulin substitution alone. The patient was
given advice with respect to his diabetes management, including training
on self-monitoring of blood sugars and application of insulin.
Due to the situation resulting from the SARS-CoV2 pandemic, the patient
could not continue treatment on an in-patient basis beyond the fifth
day. As a result, we followed up his continued treatment on an
out-patient basis. We arranged for a daily telemedicine visit with the
patient, as well as close monitoring and administration of medication by
his general practitioner. Additionally, we arranged for recurrent
out-patient check-ups for ultrasound assessment of the liver as well as
follow-up determination of laboratory parameters. (Fig.:1; Fig.:2;
Tab.:1)
During the twice-daily telemedicine visits (08:00 and 17:00), the
patient was asked to provide values for body temperature, blood sugar,
and body weight, as well as a general impression on how he was feeling.
Out-patient check-ups with clinical diagnosis, laboratory analysis and
ultrasound examinations of the liver including CEUS were carried out at
intervals of up to 14 days. The clinical visits were arranged working in
close collaboration with the GP treating the patient. Medication was
administered by the GP and adjusted as required.
The parameters over the course of recovery are outlined in table 2.
During the out-patient check-ups, the medication-based treatments were
continually adjusted with respect to the diabetes. On the sixth day of
treatment, metformin was added to the treatment plan at a dose of 1 g 2x
daily p.o. (1-0-1) due to a background of increasingly stable infective
parameters. On the twelfth day, dulaglutide (1.5 mg 1x weekly) was added
to the antidiabetic medications. At the same time, the insulin glargine
dose was reduced by increments down to 12 IU taken at night. (Fig.:2)
The intravenous antibiotic treatment was continued on an out-patient
basis under the care of the GP. Substitution was continued for a further
10 days with amoxicillin/clavulanic acid (875 mg/125 mg) 3x daily. On
the 15th day of illness, the patient reported increasingly paste-like
stool consistency. As a result, the antibiotic treatment was changed
over to ceftriaxone (1x 2 g daily i.v.) in combination with a probiotic
(E. Coli, nissle 1917). The stool sample taken at the time for
diagnostic testing in microbiology did not produce any abnormal results.
No evidence of clostridium difficile toxin A or B could be found.
Treatment with ceftriaxone was continued for a further 14 days.
Following this, no further antibiotic treatment was given.
On the 30th day of treatment, a follow-up CEUS of the liver was
performed, as well as a CT abdomen. Imaging results at this time showed
only rudimentary remnants of the large abscess in the left liver lobe
(reference lesion), whilst the abscesses in the right liver lobe could
no longer be identified. On the basis of the patient no longer having
any complaints clinically, the almost normal laboratory values and the
well-controlled diabetes mellitus, the close monitoring of this patient
via telemedicine was ended at this time. (Fig.:1; Tab.:1)
Almost 12 months following the first manifestation of the diabetes
mellitus and the large-volume liver abscesses, the patient was
re-admitted to the clinic on an in-patient basis due to complaints of
new symptoms and increased infective parameters. The underlying cause on
this occasion was acute appendicitis. An ultrasound scan of the liver
(including CEUS) and a CT scan of the abdomen at this time only revealed
small changes (most likely scar-type alterations) in the left liver lobe
with all other findings normal. (Fig.:1; Tab.:1)