A RARE SITE OF PRESENTATION OF KLEBSIELLA PNEUMONIAE INTRA-ABDOMINAL ABSCESS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Klebsiella pneumoniae, a gram-negative bacterium found in human gut flora commonly causes pneumonia, empyema, pyogenic liver abscess, catheter-related bacteremia, genito-urinary infection, nosocomial meningitis, etc. Intra-abdominal abscess caused by K. pneumonia commonly include sites such as liver and spleen. CASE PRESENTATION: 34-year-old female with PMH of diabetes mellitus presented with fever & left-sided lower abdominal pain. WBC was 16K/μL. Physical exam showed left lower quadrant abdominal tenderness. Bimanual pelvic exam revealed bulging anterior vaginal wall & cervix abutting a tense and tender mass. CT abdomen revealed ascites, 7 cm left-sided adnexal complex mass. Pelvic ultrasound described adnexal mass suspicious for abscess. She was admitted to Medical ICU and treated for sepsis secondary to intra-abdominal infection following the sepsis protocol which failed to show clinical improvement leading to septic shock. Exploratory laparotomy revealed cloudy light brown peritoneal fluid, diffuse dilated & edematous bowel, edematous bladder, diffuse fibrinous exudative coating of the serosal surfaces, edematous fallopian tubes & ovaries bilaterally, normal-appearing appendix. Vesico-uterine space was tense and obliterated, consistent with imaging for the abscess location sandwiched between the anterior wall of the uterus & posterior wall of the bladder which on surgical digital exploration drained approximately 200 mL of thick yellow purulent fluid. Culture obtained from the intra-abdominal abscess & blood culture obtained at the time of the admission was consistent with K. pneumoniae. The patient showed clinical improvement after the surgery. DISCUSSION: Intra-abdominal abscesses typically develop after perforation of a hollow viscus or colonic cancer, extension of an infection (E.g. pyogenic liver abscess) from appendicitis, diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease (E.g. Neisseria gonorrhoeae and Chlamydia trachomatis) &/or gynecological and surgical procedures. Causative organisms typically reflect normal bowel flora, complex mixture of aerobic gram-negative bacteria & anaerobic bacteria. K. pneumoniae is known to cause pyogenic liver abscess reported as a complication in diabetic patients. If presenting as a complication of Crohn's disease or diverticulitis in females, the recto-uterine space is the most common site due to the proximity of the bowel to the bladder. However, an abscess in the vesico-uterine space has not been commonly reported. Although this patient's presentation was concerning for tubo-ovarian abscess from imaging, surgical exploration ruled it out and found the abscess in vesico-uterine space. CONCLUSIONS: This case describes a rare presentation of spontaneous intra-abdominal abscess in a female diabetic patient found in the vesico-uterine space (not the liver and spleen) caused by Klebsiella pneumoniae. Reference #1: Di Carlo P, Pantuso G, Cusimano A, et al. Two cases of monomicrobial intraabdominal abscesses due to KPC--3 Klebsiella pneumoniae ST258 clone. BMC Gastroenterol. 2011;11:103. Published 2011 Sep 30. https://doi.org/10.1186/1471-230X-11-103 Reference #2: Jen-Hsien Wang, Yung-Ching Liu, Susan Shin-Jung Lee, Muh-Yong Yen, Yao-Shen Chen, Jao-Hsien Wang, Shue-Ren Wann, Hsi-Hsun Lin, Primary Liver Abscess Due to Klebsiella pneumoniae in Taiwan, Clinical Infectious Diseases, Volume 26, Issue 6, June 1998, Pages 1434–1438, https://doi.org/10.1086/516369 Reference #3: Itzhak Brook, Edith H. Frazier, Aerobic and Anaerobic Microbiology of Retroperitoneal Abscesses, Clinical Infectious Diseases, Volume 26, Issue 4, April 1998, Pages 938–941, https://doi.org/10.1086/513947 DISCLOSURES: No relevant relationships by Jagadish Akella, source=Web Response No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by Robin Sharma, source=Web Response