Liver abscess is a critical liver disease which can be classified into mainly two categories by its cause: PLA and amebic abscess.
8) PLA is a potentially life-threatening infection but can be treated appropriately upon early detection due to the recent development of imaging modalities and selection of prompt antibiotic medication. In recent reports, the death rate from PLA mortality rate was about 10%.
9-11)
Klebsiella pneumoniae is the major pathogen of primary PLA in Asians.
12)
Streptococcus milleri was the major organism found in Australians.
13) PLA can result from ascending infection in the biliary tract such as ascending cholangitis, vascular seeding secondary to bacteremia, direct invasion from a nearby source such as the gallbladder, or traumatic implantation such as perforation of the intestines.
9) Identification of pathogens from positive blood cultures might suggest the pathway of infection. If pathogens like Streptococcus or Staphylococcus are cultured, hematogenous infection might be considered.
9) This case of PLA was caused by
Streptococcus intermedius, a member of the Streptococcus anginosus group (SAG).
Streptococcus intermedius has an apparent tropism for the brain and liver.
14,15) Pyogenic liver abscesses are an uncommon, but potentially life-threatening infection. The first cases of SAG hepatic abscesses were reported in 1975.
16) Later, a study in 1981 found SAG to be the most common cause of hepatic abscesses.
17)
Streptococcus intermedius was the most frequent species found in a prospective study comparing the incidence and clinical features of SAG liver abscess to liver abscesses caused by other organisms.
18) Several studies report no association with oral infection.
19,20) To find out the cause, history taking and physical examination were conducted thoroughly. The patient had no presented risk factors such as history of drug abuse or biliary tract diseases, dental diseases, or skin disease, etc. In this case, we assume that the patient had
Streptococcus intermedius bacteremia after being treated with contaminated acupuncture needles and
Streptococcus intermedius was maybe seeded in the liver. The results of abdominal CT-scan led to liver abscess as a conclusive diagnosis, and
Streptococcus intermedius was cultured, allowing for hematogenous dissemination. Korean Oriental Medicine has basically three types of therapeutic modalities including acupuncture, moxibustion, and herbal medicine. Acupuncture and moxibustion are increasingly being recognized as safe and useful therapeutic modalities which are used globally beyond East Asia.
3,21) The abdomen is a common site for acupuncture. However, there are only a few case reports of potentially serious adverse events related to acupuncture and moxibustion,
1-5,21) while most side effects are mild and transient.
Under these circumstances, we could reach the conclusion that the patient likely had a transient bacteremia from his acupuncture or moxibustion sites that seeded the liver. The timing between the onset of his symptoms and the acupuncture with moxibustion treatments suggest a causal relationship, although causation is sometimes difficult to determine beyond doubt. Recently, there was a case of an 80-year-old woman who presented with multiple epidural abscesses after acupuncture. This case also had no direct evidence but it was accepted because the acupuncture site and abscess region corresponded exactly.
22) Our case was treated successfully by percutaneous drainage and antibiotic medication. To our knowledge, liver abscess has not previously been related to acupuncture or moxibustion in the literature. To prevent serious adverse effects of acupuncture and moxibustion, a few practices should be closely observed. These include maintaining clean needle techniques, receiving better training in anatomy, and lastly, paying greater attention to a patient's complaints. Adhering to these practices might spare a patient from many side effects and complications.