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)