Pyogenic Liver Abscess Following Acupuncture and Moxibustion Treatment
A 69-year old male presented to the family medicine clinic in Pusan National University Hospital with a 1-month history of weight loss of 9 kg, fever, and nausea. He had been in stable health except for a recent onset of hypertension. However, his blood pressure was well-controlled with a calcium channel blocker. There was no significant additional history of dental procedure, dental disease, respiratory disease, gastrointestinal disease, liver disease, or other injury/trauma. His family members were all healthy.\nTwo months prior to presentation, he visited a Korean Oriental Medicine Clinic for insomnia. Since then, he had received acupuncture on his arms and moxibustion on his abdomen three times per week by using 'Jang-chim' which was about 9 cm long and 4 mm thick. About one month after the treatments, he started feeling nauseous and feverish. He also began to slowly lose body weight and experience reduced appetite. However, he continued to receive the treatment until he visited our family medicine clinic, because his Korean oriental medicinal doctor assured him that the symptoms were acupuncture-related side effects and would resolve spontaneously without additional treatment within a few days. Nevertheless, his symptoms remained and became even worse.\nHis mental status was alert. His vital signs were as follows: body temperature, 38.0℃; blood pressure, 120/80 mm Hg; pulse rate, 90/min; and respiration rate, 23/min. On physical examination, he showed mild icteric sclera and anemic conjunctiva. Inspection of the oral cavity revealed grossly normal floor of mouth without mild dehydrated tongue. He denied any respiratory difficulties, but soon showed tachypnea. His abdomen was mildly distended and tender without lymphadenopathy and hepatosplenomegaly. There were no abdominal skin defects. Laboratory findings were as follows: while blood cell count, 14,600/mm3, with 70% neutrophils; hemoglobin, 10.8 g/dL; aspartate transaminase, 47 IU/L; alanine transaminase, 54 IU/L; alkaline phosphatase, 1,113 IU/L; lactate dehydrogenase, 348 IU/L, total bilirubin, 1.68 mg/dL; and direct bilirubin, 0.49 mg/dL. Hepatitis A, B, and C serology was negative except for reactive anti-HBs and immunoglobulin G anti-HBc antibody. Other laboratory findings including thyroid function test, blood glucose, and tumor markers were within reference ranges.\nAn abdominal computed tomography (CT) scan with contrast revealed multiseptated cystic lesions in the right and left lobes, the largest measuring about 10.0 cm in the left lobe (). Pyogenic abscess was confirmed by ultrasound-guided percutaneous needle aspiration with Gram stain and culture of the aspirate. A culture of the drained pus grew Streptococcus intermedius, a member of the "Streptococcus milleri" group, which was susceptible to clindamycin, chloramphenicol, erythromycin, penicillin, and vancomycin. Anaerobic cultures were negative. He denied upper respiratory symptoms. No primary focus was identified in the upper respiratory tract, oral cavity, or skin.\nThe patient was empirically started on intravenous cefotaxime and metronidazole before the culture and sensitivity results were available. The empiric antibiotics were changed to cefotaxime monotherapy according to the sensitivity results. After the drainage procedure and antibiotic medication, the patient's vital signs stabilized rapidly. On 18th day of his hospitalization, all laboratory findings on blood samples were normalized. Twenty-two days after admission, the patient was discharged on oral cefpodoxime to complete 4 weeks of therapy. Follow-up abdominal CT scan 6 weeks after initial antibiotic therapy and drainage procedure showed resolution of the abscess on the right lobe and a decrease in the size of the abscess on the left lobe. Another follow-up abdominal CT scan 5 months later showed complete resolution of the liver abscess. There was no sign of relapse or other side effects. Three years later, the patient is now under follow-up care without any specific problems. In this case, no primary source of infection from Streptococcus intermedius was found, except for acupuncture and moxibustion treatment history during the two months.