Leukopenia-a rare complication secondary to invasive liver abscess syndrome in a patient with diabetes mellitus: A case report.

The hypermucoviscous (hv) Klebsiella pneumoniae (KP) can cause invasive liver abscess syndrome (ILAS) including endophthalmitis dominantly in eastern Asia. We report a 80-years old woman who diagnosed with invasive liver abscess syndrome due to K. pneumoniae (KP) non-K1/K2 hvKP multi-locus sequence type ST268 by DNA amplification methods isolated from blood culture. Soon she developed endogenous endopththalmitis and immediately right vitrectomy was performed. Although intravenous 2g of ceftriaxone (CTRX) was administrated, total enucleation of right eyeball had performed due to orbital cellulitis and necrosis of eye ball finally. To find complication (i.e. endophthalmitis) with caution and to select antimicrobial agents with sufficient penetration to CNS (i.e. ceftriaxone) is needed in a patient with severe hvKP infection. Usually ILAS is caused by K1/K2 hvKP. However, to our knowledge, this is a first report of ILAS with endophthalmitis and orbital cellulitis due to non-K1/K2 hvKP ST268.

Introduction: Klebsiella pneumoniae (K. pneumoniae) is a gram-negative organism that is a known cause of pyogenic liver abscess (PLA). When K. pneumoniae causes PLA in the absence of hepatobiliary disease it is defined as invasive liver abscess syndrome (ILAS), and is commonly seen in individuals from Southeast Asia who have diabetes mellitus, cholelithiasis, or steatosis. ILAS can sometimes include metastatic spread that most commonly results in endophthalmitis or meningitis. Although K. pneumonia PLA is an endemic disease in Southeast Asia, it is now seen throughout the world and should elicit greater awareness as one of the common causes of PLA in the United States. Case Description/Methods: We present two cases of ILAS with metastatic spread causing endophthalmitis in male patients. The first case highlights known epidemiological and medical risk factors of ILAS with a 62-year-old from Southeast Asia who was diagnosed with poorly controlled type 2 diabetes mellitus (DM). The second case highlights an incidence of ILAS without any epidemiological or medical risk factors in a 36-year-old from the United States with no medical history. Both patients required interventional radiology for abscess drainage and intravenous ceftriaxone with subsequent clinical improvement and outpatient follow-ups in primary care and ophthalmology (Figure). Discussion: Liver abscesses most commonly occur with hepatobiliary disease, ILAS from K. pneumoniae is a potentially life-threatening infection and associated with significant morbidity and mortality that can occur without any hepatobiliary disease. ILAS was once commonly thought to occur typically in males and isolated in Southeast Asia, but are now seen in all sexes across the world and becoming increasingly common in the US. DM tends to be associated with K. pneumonia PLA, and the disease process also tends to be more invasive with metastatic spread to other organs, thereby leading to sepsis. Endophthalmitis is the most common infectious sequelae and is specifically associated with more virulent strains of K. pneumonia. ILAS should be part of the differential diagnosis of liver mass in the setting of sepsis, and due to K. pneumoniae metastasizing to other organ systems, early drainage and antibiotic administration is essential to decrease morbidity and mortality. A higher index of suspicion should be held for Southeast Asian diabetic males, the incidence of ILAS in all demographics is increasing, which should elicit greater awareness of risk factors, pathogenesis, and management.Figure 1.: Contrast-enhanced computed tomography scan of the abdomen in axial view demonstrating complex lesion in the left hepatic lobe (Case 1). Figure 2: Inflammation of the episclera indicative of episcleritis (Case 2).

BackgroundKlebsiella pneumonia is a well-known human pathogen, and recently, a distinct invasive syndrome caused by K. pneumoniae serotypes K1 and K2 has been recognized in Southeast Asia. This syndrome is characterized by primary liver abscess and extrahepatic complications resulting from bacteremic dissemination. We report the first adult case of primary liver abscess caused by the definite K2 serotyped pathogen, with endogenous endophthalmitis in Japan.Case presentationA 64-year-old woman was admitted to a nearby hospital for a high fever and diarrhea. She had visual loss of her right eye, renal dysfunction, and thrombocytopenia within 24 h from admission. She was transferred to our institution. On admission, she had no alteration of mental status and normal vital signs; however, she had almost complete ablepsia of the right eye. Laboratory data showed severe inflammation, liver dysfunction, thrombocytopenia, an increased serum creatinine level, and coagulopathy. Computed tomography showed a low density area in the right lobe of the liver. Invasive liver abscess syndrome probably caused by K. pneumonia was highly suspected and immediately administered broad-spectrum antibiotics for severe sepsis. Concurrently, endogenous endophthalmitis was diagnosed, and we performed vitrectomy on the day of admission. The blood culture showed K. pneumoniae infection. Percutaneous drainage of the liver abscess was also performed. Although she was discharged in a good general condition on day 22, she had complete ablepsia of the right eye. The K2A gene was detected by polymerase chain reaction (PCR), which is consistent with the K2 serotype. PCR was also positive for the virulence-associated gene rmpA. Final diagnosis was invasive liver abscess syndrome caused by K2 serotype K. pneumonia.ConclusionsAlthough the primary liver abscess caused by K. pneumoniae with a hypermucoviscous phenotype is infrequently reported outside Southeast Asia, physicians should recognize this syndrome, and appropriate diagnosis and treatment is essential for saving patients’ lives and preserving organ function, especially for visual acuity.

Case presentationThis is a 25 years old Pilipino male with no past medical history who presented with fever, rigors, fatigue and night sweats for 3 days. His symptoms progressively getting...

We present a rare case of invasive liver abscess syndrome due to Klebsiella pneumoniae (K. pneumoniae) with metastatic meningitis and septic shock. A previously healthy, 55-year-old female patient developed fever, liver abscess, septic shock, purulent meningitis and metastatic hydrocephalus. Upon admission, the clinical manifestations, laboratory and imaging examinations were compatible with a diagnosis of K. pneumoniae primary liver abscess. Her distal metastasis infection involved meningitis and hydrocephalus, which could flare abruptly and be life threatening. Even with early adequate drainage and antibiotic therapy, the patient's condition deteriorated and she ultimately died. To the best of our knowledge, this is the first case of K. pneumoniae invasive liver abscess syndrome with septic meningitis reported in mainland China. Our findings reflect the need for a better understanding of the epidemiology, risk factors, complications, comorbid medical conditions and treatment of this disease.

要旨 過粘稠性K. pneumoniaeによる尿路感染から敗血症性ショック，全身に多発感染病巣を呈した1症例を経験したため報告する。症例は70歳代の女性。血圧低下のため当院に搬送された。精査の結果，尿路感染に伴う敗血症性ショックの診断で輸液，昇圧剤とmeropenemでの治療を開始した。血液培養でstring test陽性の過粘稠性Klebsiella pneumoniae感染と判明した。腸腰筋膿瘍と化膿性椎体炎を合併したが，肝膿瘍は認めなかった。腸腰筋膿瘍と化膿性椎体炎に対しデブリードマン，椎間板掻把術を施行し，7週間の抗菌薬治療後にリハビリ目的に転院した。遺伝子分析では，mag A（K1 serotype），rmp A 陽性の過粘稠性クレブシエラが同定された。過粘稠性K. pneumoniaeによる肝膿瘍から全身に多発膿瘍を来す侵襲性肝膿瘍症候群は，1980年代より東アジアを中心に報告がみられる。呈示例では肝膿瘍を認めず，ショック，多発膿瘍を呈した。K. pneumoniae感染症において感受性良好な抗菌薬治療にも関わらず難治な経過を呈する場合，肝膿瘍を呈さずとも過粘稠性K. pneumoniae感染を想定することが重要である。

INTRODUCTION: Pyogenic liver abscesses are often polymicrobial with Escherichia coli being the most common isolated organism. Klebsiella pneumoniae is a rare cause of pyogenic liver abscesses and often affects patients with immunodeficient states. Here we discuss a rare case of primary Klebsiella pneumoniae liver abscess with subsequent metastatic infection leading to vision loss. CASE DESCRIPTION/METHODS: A 68-year-old African American woman presented with complaints of intermittent fever, chills, right upper quadrant abdominal pain and blurry vision of the left eye. Her past medical history was notable for recent laparoscopic hernia repair, cataract surgery, and hypertension. The abdominal exam showed moderate tenderness of the right upper quadrant; ophthalmic exam of the left eye revealed afferent pupillary defect and decreased visual acuity. Labs were notable for leukocytosis, total bilirubin of 2.7, AST of 161, ALT of 135 and an alkaline phosphatase of 110. CT abdominal imaging revealed an abscess within the dome of the right liver measuring 5.2 × 6.3 × 4.1 cm. She was admitted to the intensive care unit and started on broad-spectrum empiric antibiotic therapy. Blood culture revealed gram-negative rods. B-scan ultrasonography of the left eye showed vitritis with loculation confirming the diagnosis of endophthalmitis. Intravitreal antibiotics were promptly administrated. She underwent CT guided sampling and drainage of the hepatic abscess with fluid culture growing the same organism identified in the blood cultures: mucoid Klebsiella pneumoniae complex. The patient was diagnosed with invasive Klebsiella bacteremia, liver abscess, and endophthalmitis and developed permanent vision loss in the left eye despite prompt intravenous and intravitreal antibiotic therapy. DISCUSSION: Klebsiella pneumoniae invasive liver abscess syndrome is a rare condition in the United States making timely diagnosis and treatment a challenge per se. Known risk factors for invasive liver abscess syndrome include diabetes mellitus, hepatobiliary disease, alcoholism, chronic renal failure, and cancer. While our patient did not have any of these specific comorbidities and had no recent international travel, her age, and recent surgical interventions likely predisposed her to an immunocompromised state. Invasive liver abscess syndrome can be fatal with poor prognosis if treatment is delayed. Timely abscess drainage and administration of intravenous antibiotics is crucial and should be implemented early on in the clinical course.

BackgroundProstate abscess is usually a complication of acute urinary tract infection. Invasive liver abscess syndrome is characterized with Klebsiella pneumoniae related multiple organ metastasis. Concomitant pyogenic liver abscess and prostate abscess have rarely been reported. Recurrent episode of liver abscess is even rarer.Case presentationWe report a 71-year-old male with acute bacterial prostate abscess and urinary tract infection caused by K. pneumoniae associated with multiple liver abscess, psoas muscle abscess and osteomyelitis. Blood culture and urine culture yielded K. pneumoniae, which confirmed the diagnosis of invasive liver abscess syndrome caused by K. pneumoniae. The patient was successfully treated with empirical antibiotics for 6 weeks.ConclusionsThis case emphasizes the importance of timely and accurate diagnosis followed by appropriate treatment in disseminated K. pneumoniae infection to prevent significant morbidity and mortality.

Introduction: Invasive liver abscess syndrome is a rare metastatic infection associated with primary Klebsiella pneumoniae liver abscesses typically seen in Asian countries. Disease progression often results in Klebsiella pneumoniae endogenous endophthalmitis (KPEE). Reported risk factors for KPEE include liver abscesses, diabetes mellitus, and systemic immunocompromise. Limited data exists among Hispanics through a small number of isolated case reports. We present a case of a Hispanic female diagnosed with KPEE who developed blindness, which later resolved with prompt intravitreal antibiotics, highlighting a possible treatment for an otherwise visually devastating disease. Case Description/Methods: A 75-year-old Hispanic female with history of diabetes mellitus presented to the emergency department with weakness and flank pain. Computed tomography showed a multicystic/septated peripherally enhancing lesion in the hepatic dome near the inferior vena cava measuring 3.2 cm. Blood cultures grew Klebsiella pneumoniae on hospital day two likely secondary to the liver abscess. IR-guided drainage was not possible due to proximity of the Inferior Vena Cava (IVC) thus she was treated with Ceftriaxone and Metronidazole. Despite this, she developed complete vision loss in the right eye and hypopyon on hospital day three. Ophthalmology was consulted and recommended emergent transfer for intravitreal antibiotics. The patient was transferred and treated within 12 hours and upon discharge already had partial recovery of vision. (Figure) Discussion: While our patient had a suspected Klebsiella liver abscess, drainage of the abscess was not possible due to its proximity to the IVC resulting in endophthalmitis and right eye blindness. Invasive liver abscess syndrome with KPEE is a rare and devastating disease with significant morbidity and mortality. Even with aggressive treatment within 24 hours, vision loss is typically permanent. However, our patient did have some restoration of vision and we propose that it was due to prompt administration of intravitreal antibiotics within 12 hours. Greater awareness of this devastating complication will result in more cases which will hopefully help to establish further guidelines concerning management and improved outcomes. It will also hopefully lead to faster treatment of patients with KPEE and potentially if intravitreal antibiotics can be administered within twelve hours, the medical community may see a higher probability of vision restoration.Figure 1.: Slit-lamp examination of the right eye - hypopyon with conjunctival injection and chemosis. (b) Photomicrograph of the anterior chamber aspirate shows numerous neutrophils and bacilli. (c) Orbital CT revealed panophthalmitis and right orbital cellulitis with preseptal and retroorbital involvement.

An 82-year-old female patient was admitted to our hospital for visual acuity loss in both eyes. The patient was diagnosed with invasive liver abscess syndrome and bilateral endophthalmitis due to Klebsiella pneumoniae 4 days after the onset of ocular symptoms. The liver abscess improved by broad-spectrum antibiotics and intravitreal injection, but bilateral blindness occurred. Most literature reported fever as the first symptom of invasive abscess syndrome, but this case had no fever at the onset of ocular symptoms. Delayed invasive liver abscess syndrome diagnosis might cause poor visual acuity prognosis.

We report a case of Klebsiella pneumoniae invasive liver abscess syndrome (KPILAS) with endophthalmitis-caused blindness as the first symptom after enema. The patient had diabetes, and his blood glucose was poorly controlled. She developed hematuria after four enemas for cosmetic purposes and later became blind. The eye discharge was cultured, which revealed a Klebsiella pneumoniae infection. B ultrasound did not show liver lesions, but computed tomography exhibited abscesses in the right lobe of the liver. Magnetic resonance imaging of the head indicated abscesses. These confirmed the diagnosis of invasive liver abscess syndrome. The patient was given ophthalmic and systemic anti-infection treatments, and her condition was effectively controlled. Unfortunately, the diseased eye still needed to be removed. This case underlines the necessity of avoiding unnecessary risky procedures (such as enemas) in vulnerable populations, the importance of early detection of invasive liver abscess syndrome, and the advantage of computed tomography in detecting liver abscesses.

A woman in her 70s was hospitalized and was diagnosed with liver abscess and managed with antibiotics in a previous hospital. However, she experienced altered consciousness and neck stiffness during treatment. She was then referred to our hospital. On investigation, we found that she had meningitis and right endophthalmitis concurrent with a liver abscess. Klebsiella pneumoniae was detected from both cultures of the liver abscess and effusion from the cornea. A string test showed a positive result. Therefore, she was diagnosed with invasive liver abscess syndrome. Although she recovered from the liver abscess and meningitis through empiric antibiotic treatment, her right eye required ophthalmectomy. In cases where a liver abscess presents with extrahepatic complications, such as meningitis and endophthalmitis, the possibility of invasive liver abscess syndrome should be considered, which is caused by a hypervirulent K. pneumoniae.

(hvKP) strains can cause invasive liver abscess syndrome, which is characterised by liver abscess with extrahepatic compli-cations including central nervous system involvement, necrotising fasciitis or endophthalmitis (Siu et al. 2012). hvKP was first reported in Taiwan in 1985 and, since then, infections caused by hvKP have been described in several parts of the world, with many cases reported in Southeast Asia (Li et al. 2014). In the Americas, in-vasive liver abscess syndrome has been reported in the United States of America, Canada and Argentina (Siu et al. 2012). However, this strain has not been previously reported in Brazil. Recently, a 57-year-old woman with diabetes mellitus was admitted to the emergency de-partment with a history of fever, nausea, vomiting and mental confusion for five days. On the day of admission, she was comatose, icteric and had a poor general appear-ance. Her temperature was 37.8°C and her blood pres-sure, pulse and respiratory rate were 110/60 mmHg, 96 beats/min and 48 breaths/min, respectively. Respiratory and cardiovascular auscultations were normal; however, a neurological examination revealed neck rigidity. Bac-terial meningitis was suspected and ceftriaxone 2 g IV q12 h was empirically prescribed after performing a di-agnostic lumbar puncture. Her cerebrospinal fluid (CSF) was xanthochromic and showed glucose 0.0 mg/dL, pro-tein 485 mg/dL and 8,640 cells/mm

BackgroundK. pneumoniae liver abscess (KPLA) mostly involves the right lobe. We present a case of K. pneumoniae caudate liver abscess with invasive liver abscess syndrome (ILAS) was rarely identified.Case presentationA 53-year-old man with elevated glycated hemoglobin with chills, rigors and a fever of five days. The patient presented with tachycardia and fever. Physical examination revealed tenderness over the right abdomen was elicited. In particular, the inflammatory markers were markedly elevated, and computerized tomography (CT) showed pulmonary abscess, pulmonary embolism and caudate liver abscess. The patient’s sequential organ failure assessment (SOFA) score was 10 points. Klebsiella pneumoniae was isolated from sputum, urine and blood. With the suspicion of liver abscesses, ILAS and sepsis. The patient was successfully treated with antibiotics. He returned to close to his premorbid function.ConclusionK. pneumoniae caudate liver abscess was rare. This is the first detailed report of K. pneumoniae caudate liver abscess with invasive liver abscess syndrome. Patients with cryptogenic K. pneumoniae liver abscess are advised to undergo an examination of intestinal barrier function. The study indicates that in patients with K. pneumoniae liver abscess, a caudate liver abscess size of ≤ 9.86 cm² may be characteristic of those suitable for conservative treatment of invasive liver abscess syndrome.

Background: Klebsiella pneumoniae has gained recognition for its association with invasive liver abscess syndrome (ILAS). ILAS is associated with a hypervirulent strain of K pneumoniae and can impact immunocompetent as well as immunocompromised patients. Case Report: A 42-year-old Hispanic male with no significant past medical history was admitted with complaints of subjective fevers and worsening fatigue. The patient was found to have multiple septic pulmonary emboli, a prostate abscess, a seminal vesicle abscess, bilateral frontoparietal and left temporal infarcts thought to be due to septic emboli, pyelonephritis, endophthalmitis, and hepatic abscesses. Cultures grew K pneumoniae that was determined to be the hypervirulent strain associated with ILAS. The patient was treated for a total of 71 days, including ceftriaxone and multiple intravitreal injections with ceftazidime. Conclusion: Notably, this case report details a disease state new to Colorado. Pharmacists are able to assist in the care of ILAS with antibiotic selection, considering sites of infection and encouraging appropriate consultation of specialized care teams.