Cause Of Pyogenic Liver Abscess Research Articles

206. Prevalence of liver abscess in patients with Klebsiella pneumoniae bacteremia during a 5-year experience in a tertiary hospital in Thailand

Abstract Background The incidence of liver abscess in Thailand has increased in number nowadays. K. pneumoniae is the most common cause of pyogenic liver abscess in the recent large series. Liver abscess can be a complication of K. pneumoniae bacteremic patients. We aimed to study the prevalence of liver abscess in patients with K. pneumoniae bacteremia and the comparison in clinical and laboratory characteristics of patients with K. pneumoniae between a group with liver abscess and the other without liver abscess. Methods This is a retrospective study; data were collected in Bhumibol Adulyadej Hospital among patients who were diagnosed with K. pneumoniae bacteremia between January 2014 – December 2019 and compared the difference in clinical and laboratory characteristics of patients between a group with liver abscess and the other without liver abscess. Results Of All 758 patients with K. pneumoniae bacteremia, 335 (44.19%) patients were done abdominal imaging, and 37 (4.9%) patients were found with liver abscess. The mean age was 65 years old, and most were male. Comorbidities were present in almost half of the patients including diabetes (118 patients, 35.22%), previous hepatobiliary surgery (21, 6.26%), and history of cancer (70, 20.90%). The other demographic data are shown in Table 1. Patients with liver abscess had diabetes (54.1% vs 29.3%, p-value = 0.082) and fever (91.89% vs 76.84%, p-value = 0.056) more than patients without abscess, however only 29.7% of patients with liver abscess had abdominal pain. Elevated transaminases above 2 times the upper limit of normal range are more frequent among patients with liver abscess than patients without abscess, for AST; 54.1%vs 35.30% (p-value = 0.026) and ALT; 40.5% vs 25.20% (p-value = 0.048). Clinical and laboratory characteristics are shown in Table 2.Table 1:Demographic data of patients with K. pneumoniae bacteremiaTable 2:Clinical and laboratory characteristics of patients with K. pneumoniae bacteremia Conclusion The prevalence of liver abscess in patients with K. pneumoniae bacteremia is 37 from 758 (4.9%). Liver abscess should be suspected in K. pneumoniae bacteremic patients who have elevated transaminases above 2 times the upper limit of normal range regardless of abdominal pain. Disclosures All Authors: No reported disclosures

Neglected Biliary Stent with Hepatico-lithiasis Causing Left Lobe Pyogenic Liver Abscess with Rupture into Left Pleural Cavity: A rare Life-threatening Emergency

Abstract Biliary tract disease is currently the leading cause of pyogenic liver abscess (PLA) and complications of rupture are associated with high mortality and morbidity even with current medical knowledge advancement. We report a 35-year-old female who presented in emergency setting with complaints of jaundice, abdominal pain, fever, and respiratory distress. Patient had prior history of endoscopic management of biliary stones about 6 years back followed by asymptomatic period. Patient was managed by percutaneous drainage of left lobe liver abscess and left pleural empyema after initial resuscitation with further investigations revealing biliary stent with left hepatic abscess with transdiaphragmatic extension into left hemithorax. Neglected biliary stent has been reported to cause severe cholangitis with PLAs and these patients require immediate timely attention to the management of abscess and its complications.

Point-of-care Ultrasound Identification of Hepatic Abscess in the Emergency Department.

A 92-year-old female with past medical history of hypertension presented to the emergency department with pain in her right shoulder, right flank, and right upper quadrant of her abdomen. Point-of-care ultrasound (POCUS) and computed tomography imaging showed concerns for multiple large hepatic abscesses. Percutaneous drainage removed 240 millileters of purulent fluid that identified Fusobacterium nucleatum, a rare cause of pyogenic liver abscess. Emergency physicians should keep hepatic abscess on their differential for right upper quadrant abdominal pain and can use POCUS for expeditious diagnosis.

Pyogenic Liver Abscess: Contemporary Trends in a Tertiary Institute.

Pyogenic liver abscess (PLA) is an uncommon but potentially life-threatening condition. In recent years, advances in diagnostics and management have led to early diagnosis and treatment and decreased mortality. We present recent data from a large series of patients with PLA and examine the trends in the management of PLA over a period of 50 years. The medical records of all patients admitted to the Shaare Zedek Medical Center, Israel, between January 2011 and December 2021 with a primary or secondary diagnosis of PLA were reviewed retrospectively. : Ninety-five patients with PLA were identified. Thirty-eight (40%) were female. The median patient age was 66 years (range 18-93). The diagnosis of PLA in all patients was confirmed with abdominal computed tomography (CT). In twenty patients (21.1%), PLA was not diagnosed by the initial abdominal US. Most abscesses were right-sided. Biliary tract origin was the most common underlying cause of PLA (n = 57, 60%), followed by cryptogenic etiology (n = 28, 30%). Escherichia coli, Klebsiella pneumoniae, and Streptococcus species were most commonly identified. The most common primary treatment modality was percutaneous drainage (PD), which was performed in 81 patients (85.3%). Fourteen patients (14.7%) were treated medically without intervention, and two patients (2.1%) were treated surgically following a failure of PD. Four patients died as a direct result of PLA. Patients diagnosed with PLA are older, the male predominance is less pronounced, and the offending pathogens are likely to originate from the biliary tract. This study questions the utility of abdominal US as the initial diagnostic imaging in patients with suspected PLA (versus CT) and demonstrates improved outcomes for patients with PLA over the years.

Siderophore iucA of hypermucoviscous Klebsiella pneumoniae promotes liver damage in mice by inducing oxidative stress

The hypermucoviscosity/hypervirulent K. pneumoniae (hvKP) is a dominant cause of pyogenic liver abscess (PLA) and has contributed to the endemicity of disease in Asian country. The siderophore aerobactin (iucA) is highly expressed in hvKP and acting virulence role during hvKP infection. However, its role in the PLA is poorly understood. We constructed iucA deletion mutant (ΔiucA-hvKP852) and used animal study to characterize the role of siderophore iucA in K. pneumoniae liver abscess. The animal experiments showed that ΔiucA-hvKP852 strain had lower virulence in mice compared to hvKP852 wild type strain. At 24 h after infection, only two of ten mice developed liver abscess during infection with ΔiucA-hvKP852 strain, while nine of ten mice infected with wild type hvKP852 strain showed multiple lesions of liver abscess. The liver tissue infected with ΔiucA-hvKP852 exhibited low reactive oxygen stress levels compared to those infected by wild type hvKP852 strain (P < 0.05). The results suggest that siderophore iucA play an important role in the liver abscess by inducing oxidative stress.

S3214 Two Cases of Klebsiella pneumoniae Liver Abscess With Metastatic Infection

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).

Anaerobe coverage is important for the prognosis of pyogenic liver abscess: A population-based study in Korea

BackgroundGram-negative bacteria such as Klebsiella pneumoniae and Escherichia coli are the most common cause of pyogenic liver abscess (PLA).We investigated whether the use of anaerobic-covering antibiotics is essential for the treatment of pyogenic liver abscess. MethodsWe analyzed the Health Insurance Review and Assessment Service data in Korea between 2007 and 2017. We classified PLA into two groups: a group using antibiotics that inhibited only aerobic strains (anaerobe (-) group) and a group using antibiotics that inhibited both aerobic and anaerobic strains (anaerobe (+) group). The primary outcome was the difference in in-hospital mortality between the two groups. ResultsDuring this period, a total of 30,690 PLA patients were obtained. There were 6733 patients in the anaerobe (-) group and 23,957 patients in the anaerobe (+) group. In-hospital mortality was significantly lower in the anaerobe (+) group than the anaerobe (-) group (7.9% vs. 15.6%, p < 0.001). In multivariate analysis, the use of anaerobic antibiotics reduced the in-hospital mortality by 42% (odds ratio 0.42, 95% confidence interval 0.38–0.46, p < 0.001) after adjusting for age and comorbidities. Furthermore, the improvement of in-hospital mortality was present regardless of the presence of cancer or diabetes. ConclusionThe use of broad-spectrum empirical antibiotics covering anaerobic strains is important for the treatment of pyogenic liver abscess.

Structural and biological insights into Klebsiella pneumoniae surface polysaccharide degradation by a bacteriophage K1 lyase: implications for clinical use

BackgroundK1 capsular polysaccharide (CPS)-associated Klebsiella pneumoniae is the primary cause of pyogenic liver abscesses (PLA) in Asia. Patients with PLA often have serious complications, ultimately leading to a mortality of ~ 5%. This K1 CPS has been reported as a promising target for development of glycoconjugate vaccines against K. pneumoniae infection. The pyruvylation and O-acetylation modifications on the K1 CPS are essential to the immune response induced by the CPS. To date, however, obtaining the fragments of K1 CPS that contain the pyruvylation and O-acetylation for generating glycoconjugate vaccines still remains a challenge.MethodsWe analyzed the digested CPS products with NMR spectroscopy and mass spectrometry to reveal a bacteriophage-derived polysaccharide depolymerase specific to K1 CPS. The biochemical and biophysical properties of the enzyme were characterized and its crystal structures containing bound CPS products were determined. We also performed site-directed mutagenesis, enzyme kinetic analysis, phage absorption and infectivity studies, and treatment of the K. pneumoniae-infected mice with the wild-type and mutant enzymes.ResultsWe found a bacteriophage-derived polysaccharide lyase that depolymerizes the K1 CPS into fragments of 1–3 repeating trisaccharide units with the retention of the pyruvylation and O-acetylation, and thus the important antigenic determinants of intact K1 CPS. We also determined the 1.46-Å-resolution, product-bound crystal structure of the enzyme, revealing two distinct carbohydrate-binding sites in a trimeric β-helix architecture, which provide the first direct evidence for a second, non-catalytic, carbohydrate-binding site in bacteriophage-derived polysaccharide depolymerases. We demonstrate the tight interaction between the pyruvate moiety of K1 CPS and the enzyme in this second carbohydrate-binding site to be crucial to CPS depolymerization of the enzyme as well as phage absorption and infectivity. We also demonstrate that the enzyme is capable of protecting mice from K1 K. pneumoniae infection, even against a high challenge dose.ConclusionsOur results provide insights into how the enzyme recognizes and depolymerizes the K1 CPS, and demonstrate the potential use of the protein not only as a therapeutic agent against K. pneumoniae, but also as a tool to prepare structurally-defined oligosaccharides for the generation of glycoconjugate vaccines against infections caused by this organism.

An unusual cause of pyogenic liver abscess. The conundrum of broom splinter. Report of two cases

Pyogenic liver abscess is an uncommon but potentially fatal disease. Very few cases of liver abscess due to foreign bodies have been reported. We report our experience in two patients who were successfully managed for liver abscess due to impaled broom splinter. Broom splinters were swallowed unnoticed during consumption of Jute leaves (Corchorus olitorus) (”Ewedu”) soup. Definitive diagnoses in both cases were made at surgery. This is the first case of broom stick-induced liver abscess to be reported in the literature.

S3657 Delayed Presentation of Pyogenic Liver Abscess Following an Appendectomy

Introduction: Historically, appendicitis was a common cause of pyogenic liver abscess (PLA), however, antibiotics and early surgical intervention have improved outcomes. This case depicts a delayed presentation of liver abscess secondary to perforated appendicitis. Case Description/Methods: A 34-year old male presented with a 2-week history of right upper quadrant pain, 4 days of fever with chills, nausea, and vomiting. Six months ago he had a perforated appendix with a subsequent appendectomy. He denied any alcohol use, illicit drug use, and recent travel. Vitals revealed a temperature of 101.1°F, HR of 112, and SBP fluctuating from 70-90 mmHg. Labs were significant for WBC 18.2, AST 50, ALT 66, ALP 255, TBILI 1.0, INR 1.64, PT 18.5, PTT 30.7, and lactate 3.4. A CT of the abdomen without contrast demonstrated a 6.0 x 9.0 cm bilobed lesion in the right lobe of the liver suspicious for hepatic abscess. The abscess was percutaneously drained and cultures grew moderate E. coli and many Bacteroides fragilis with stool ova/parasite positive for Blastocystis hominis. Based on antimicrobial sensitivity the patient was discharged on ciprofloxacin and metronidazole. On outpatient follow-up, repeat imaging showed that the abscess had decreased in size to 3.0 x 3.0 cm and was responding to antibiotic treatment and drainage. Discussion: Appendicitis was previously one of the most common etiologies for liver abscesses, however with better diagnostic and treatment modalities for appendicitis, it is seldom considered. PLA is defined as one or more discrete lesions in the liver associated with a positive bacterial culture and accounts for 48% of all visceral abscesses in the US. PLA is usually due to polymicrobial infections, most commonly E. coli and Klebsiella but may also include Streptococcus, Staphylococcus, and anaerobes. Risk factors include male gender, advanced age, diabetes, chronic PPI use, malignancy, cirrhosis, and liver transplant history. Liver abscesses are most commonly found in the right lobe of the liver due to receiving venous drainage from the cecum and ascending colon. Screening colonoscopy should be considered when there are cultures with anaerobic growth as anaerobic abscesses are associated with silent colon cancer. In-hospital mortality for PLA is estimated to range between 2.5-19%. Management of PLA is largely dependent on the size of the abscess. Antibiotic use is the treatment of choice for small abscesses of < 3-5 cm, while anything larger also requires percutaneous or surgical drainage.Figure 1.: CT abdomen pelvis without IV contrast demonstrated a 6.0 x 9.0 cm bilobed lesion in the right lobe of the liver suspicious for hepatic abscess.

S2843 Pyogenic Liver Abscess Presenting as Obstructive Jaundice From Klebsiella Pneumoniae in Texas

Introduction: A pyogenic liver abscess (PLA) is a suppurative infection involving the hepatic parenchyma and account for roughly 80% of all liver abscesses. Traditionally, PLA was associated with intra-abdominal infections or leakage of intrabdominal bowel contents and was polymicrobial. One organism of interest is Klebsiella pneumoniae, which is the leading cause of PLA in several parts of Asia, making up 50-85% of cases. PLA with K. pneumoniae is becoming more common globally, especially here in the Unites States. PLA from K. pneumoniae often occurs in the absence of intraabdominal or hepatobiliary disease and has been associated with diabetes mellitus and underlying colorectal cancer. Early recognition and treatment of PLA is crucial to prevent development of bacteremia. PLA at presentation often includes fever (seen in 90% of cases), abdominal pain (50-75%), and elevated alk phos (60-90%), while jaundice and compression of the biliary tree (12-27%) is rarer. Case Description/Methods: A 59-year old man visiting from the Philippines with a medical history of HTN and type 2 DM presenting with five days of worsening fatigue, nausea, non-bloody vomiting, and scleral icterus was found to be in septic shock. He had developed the symptoms while in Mexico. Physical exam was notable for jaundice and hepatomegaly with a moderately distended abdomen. Presenting labs showed an elevated lactate, hyperbilirubinemia (total bilirubin 11.4, conjugated bilirubin 7.1), and increased alk phos. CT abdomen/pelvis showed a large, 12.9 cm hypo-attenuating cystic liver mass with ill-defined septations and peripheral enhancement. Blood cultures grew Klebsiella pneumonia. Patient underwent two percutaneous drain placement procedures, both of which incompletely drained the fluid. Roughly two weeks after presentation, while still in the hospital, he underwent exploratory laparotomy and successful drainage of hepatic abscess. He was monitored a few days afterwards with down trending labs before being discharged home. Discussion: Here we presented a case of septic shock and obstructive jaundice secondary to a pyogenic liver abscess with Klebsiella pneumoniae. The patient had multiple risk factors for this disease such as diabetes and being from Southeast Asia. The treatment was complicated by multiple percutaneous and surgical interventions before being stable for discharge. Being aware of K. pneumoniae causing PLA should be included on a differential for obstructive jaundice is necessary.

A retrospective analysis of pyogenic liver abscess and antibiotic resistivity of common pathogens in Peshawar

Background: Pyogenic liver abscess (PLA) is a rare but life-threatening disease, with a frequency ranging from 10.83 to 17.45 per 100,000 persons. The major cause of PLA is bacterial infection of liver parenchyma. The present research study was designed to investigate the common microbes causing PLA in Peshawar (Pakistan) and to evaluate a variety of the most capable and efficient antibiotics for treatment of PLA.&#x0D; Methods: A 7-year (2012 - 2018) retrospective demographic study of medical records of all PLA patients (n = 379) admitted to the Hayatabad Medical Complex (HMC) and Khyber Teaching Hospital (KTH) was initially performed. The demographic study was followed by biochemical tests and antibiotic resistivity tests of microorganisms, isolated from available samples and selected from literature using web services.&#x0D; Results &amp; Conclusion: The demographic data revealed that 70% of the PLA patients were under the age of 50, with male predominance (male to female ratio of 3:1). It was concluded that K. pneumonia, poly-microbes (K. pneumonia and Citrobacter), and E. coli are the most common microbes involved in causing PLA in the population of Peshawar. E.coli, Citrobacter and K. pneumonia were sensitive to Cefixime and Ciprofloxacin (100% sensitivity rate), but showed significant resistance against Amoxycillin, Oxacillin and Fusidic Acid. It is, therefore, prudent to practice susceptibility-directed antibiotic therapy.

Pyogenic Liver Abscesses Caused by Acute Appendicitis: Frequency and Diagnostic and Therapeutic Recommendations.

Background: Pyogenic liver abscesses (PLA) are caused by biliary diseases or hematogenous spreading of mostly intra-abdominal infections. Liver abscesses resulted in hematogenous spreading of infections via the portal vein, such as abscesses caused by acute appendicitis. Pyogenic liver abscesses associated with appendicitis have rarely been described in the literature, especially in adults. The standard therapeutic procedures for liver abscesses are broad-spectrum antibiotic therapy and percutaneous drainage. Surgery for liver abscesses is required in cases of unsuccessful processes. Patients and Methods: A retrospective analysis of patients with liver abscesses between January 2005 and June 2013 was performed. Parameters investigated included demographics, etiologies of abscesses, treatment modalities, and germ spectrum including antibiotic profile. Five cases of PLA caused by appendicitis were reviewed in detail. Results: During the study period, 49 patients with PLA and 1,986 patients with acute appendicitis were treated in our hospital. Twenty-one patients with PLA were treated with antibiotic agents and computed tomography (CT)-guided drainage. Liver resections were necessary in 29 of the patients with PLA. In five patients with PLA, abscesses were caused by an acute appendicitis (9.4% of all PLA, 0.25% of all appendicitis operations). Diagnosis of appendicitis as cause of PLA was made during surgery for liver resections in three patients. Previous imaging was not clear in all cases of PLA caused by appendicitis. The most common pre-operative symptoms in patients with PLA caused by appendicitis were fever and right upper quadrant tenderness. Discussion: Pyogenic liver abscesses caused by acute appendicitis are rare. In the study period of eight and one-half years nearly 2,000 cases of acute appendicitis were treated and five of these patients developed liver abscesses (0.25%). Pyogenic liver abscesses should be considered in patients with unusual high infectious parameters, septic symptoms, and detection of unknown liver lesions.

Hypervirulent Klebsiella pneumoniae - clinical and molecular perspectives.

Hypervirulent Klebsiella pneumoniae (hvKp) has emerged as a concerning global pathogen. hvKp is more virulent than classical K.pneumoniae (cKp) and capable of causing community-acquired infections, often in healthy individuals. hvKp is carried in the gastrointestinal tract, which contributes to its spread in the community and healthcare settings. First recognized in Asia, hvKp arose as a leading cause of pyogenic liver abscesses. In the decades since, hvKp has spread globally and causes a variety of infections. In addition to liver abscesses, hvKp is distinct from cKp in its ability to metastasize to distant sites, including most commonly the eye, lung and central nervous system (CNS). hvKp has also been implicated in primary extrahepatic infections including bacteremia, pneumonia and soft tissue infections. The genetic determinants of hypervirulence are often found on large virulence plasmids as well as chromosomal mobile genetic elements which can be used as biomarkers to distinguish hvKp from cKp clinical isolates. These distinct virulence determinants of hvKp include up to four siderophore systems for iron acquisition, increased capsule production, K1 and K2 capsule types, and the colibactin toxin. Additionally, hvKp strains demonstrate hypermucoviscosity, a phenotypic description of hvKp in laboratory conditions that has become a distinguishing feature of many hypervirulent isolates. Alarmingly, multidrug-resistant hypervirulent strains have emerged, creating a new challenge in combating this already dangerous pathogen.

PLEURAL EFFUSION CAUSED BY KLEBSIELLA PYOGENIC LIVER ABSCESS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Historically, pyogenic liver abscesses were most commonly of Escherichia coli or polymicrobial etiology. Klebsiella pneumoniae has become a rising cause of pyogenic liver abscesses, particularly in Taiwan, since 1996 [1]. Predisposing factors of Klebsiella primary liver abscess (KLA) include diabetes, prior antibiotic use, and specific virulence factors including the K1 capsular antigen genotype[2]. This case details a middle-aged, non diabetic, male who presented with KLA that resulted in metastatic pleural empyema after abscess drainage. CASE PRESENTATION: A 52 year old male without medical history, presented with sharp, right upper quadrant moderate abdominal with radiation to the back for three months. He had mild guarding with active bowel. One month prior, he had a computed tomography (CT) of the abdomen showed cholecystectomy and a complex fluid collection posterior to the right hepatic lobe that measured 3.0 x 2.5 cm. A repeated CT upon this admission revealed a 5 x 3.1 x 4.8 cm heterogeneous collection along the posterior aspect of the right lobe of liver. The fluid collection was increased in size compared to prior imaging and concerning for an abscess. The patient underwent CT-guided abscess drainage with a drain placement five days after admission. Antibiotic treatment with Zosyn was initiated; the patient also received Flagyl and vancomycin. The culture of the abscess grew K. pneumoniae. Shortly following the abscess drainage, the patient began exhibiting shortness of breath with decreased breath sounds, dyspnea with activity, ongoing low grade fever, and leukocytosis. At the day of the drainage, his white blood cell count (WBC)15,800. CT-guided pleural fluid drainage with pigtail chest tube placement done. Pleural fluid analysis showed a lactate dehydrogenase(LDH) of 2,628 and a total protein (TP) of 4.7 consistent with exudate, and a pH of 7. The culture of the pleural fluid also grew K. pneumoniae. Infectious disease recommendation to continue the course of Zosyn for a total of four weeks from the day of the abscess drain placement. A repeated CXR reported slight improvement of the right pleural effusion with symptomatic improvement with chest tube placement and significant drainage of pleural fluid. The patient was seen as an outpatient with significant improvement. DISCUSSION: The clinical significance of the increasing trend of KLA should be noted due to potential metastasis, most commonly endophthalmitis and meningitis, which occur more frequently than in other microbial etiologies of liver abscesses. In a 1998 study done in Taiwan 11.9% of KLA resulted in metastatic complications compared to 0% of polymicrobial liver abscesses [2]. Furthermore, the significant risk factor of diabetes mellitus as a predisposing factor. CONCLUSIONS: To keep in our mind that pleural empyema due to Klebsiella Pneumoniae can be a consequnt complication of liver abscess. Reference #1: 1. Yang CC, Yen CH, Ho MW, & Wang JH (2004). Comparison of pyogenic liver abscess caused by non-Klebsiella pneumoniae and Klebsiella pneumoniae. J Microbiol Immunol Infect., 37(3), 176. Reference #2: 2. Wang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, Wann SR, & Lin HH (1998). Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis., 26(6), 1434. DISCLOSURES: No relevant relationships by WAQAS HAFEEZ, source=Web Response No relevant relationships by Nooraldin Merza, source=Web Response No relevant relationships by Mazin Saadaldin, source=Web Response

2510 Bacteremia With Liver Abscess and Endophthalmitis: A Rare Case of Invasive Klebsiella Pneumoniae Syndrome

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.

2308 A Rare Cause of Pyogenic Liver Abscess

INTRODUCTION: Pyogenic liver abscess (PLA) is a rare clinical entity with an annual incidence of 0.5 to 0.8 percent. While these infections are typically polymicrobial, Staphylococcus aureus has also rarely been implicated. Here, we report a case of a community acquired Methicillin resistant Staphylococcus aureus (MRSA) hepatic abscess, which responded to clindamycin. CASE DESCRIPTION/METHODS: A 67-year-old man with history of untreated chronic hepatitis C and intranasal heroin abuse presented with shortness of breath, right sided pleuritic chest pain and generalized abdominal discomfort. Physical examination was notable for skin pallor, cachexia and right upper quadrant tenderness. Laboratory tests revealed albumin 2.6 g/dl (ref: 3.8-5.2), total bilirubin 2.8 mg/dl (ref: 0.2-1.2), direct bilirubin 1.3 mg/dl (ref: 0.0-0.2), hemoglobin 6 g/dl (ref: 12.9-16.8) and no leukocytosis. Computed tomography (CT) scan of abdomen demonstrated an ill-defined right hepatic lobe mass concerning for hepatocellular carcinoma (HCC). A triple phase CT scan revealed liver cirrhosis and a complex cystic solid mass 10 × 5 × 6 cm in size, raising suspicion for HCC versus a hepatic abscess (Figure 1). Biopsy yielded pus and a pig tail catheter was placed. He was started on ampicillin-sulbactam for possible polymicrobial hepatic abscess, but it was later switched to IV Vancomycin when the cultures grew MRSA (Figure 2). On further testing, no source of infection was identified. He left against medical advice and was discharged with four weeks of clindamycin. A repeat CT scan five months later showed resolution of the hepatic abscess and the drain was removed (Figure 3). DISCUSSION: Community acquired MRSA is an uncommon cause of PLA with only a few cases reported in literature. The source of infection if identified is usually cutaneous or intraabdominal. We could not identify any infectious foci in our patient. Radiographic appearance of multi-loculated hepatic abscess can masquerade HCC, as in our patient, warranting further diagnostic workup. The mainstay of treatment is drainage and prolonged antibiotic therapy. Intravenous vancomycin is the drug of choice. Linezolid has been used as an oral alternative previously, but our patient responded well to clindamycin, suggesting that it could be a less expensive but equally efficacious choice. Surgical intervention maybe necessary if there is no improvement after 4 to 7 days of percutaneous drainage or if there is viscous pus in thick-walled or multilobulated abscesses.

Klebsiella Pneumoniae Visceral Organ Abscesses – Clinical Characteristics

In recent years, Klebsiella pneumonia (KP) has emerged as the predominant cause of pyogenic liver abscess in Asia. KP - as the causative microorganism in other visceral organ abscesses-is less described. In this study, we seeked to describe the clinical characteristics of KP visceral organ abscesses in our institution and evaluated the prescription practices of physicians with regard to antibiotic therapy. A retrospective analysis of patients with culture positive (blood or abscess aspirate) KP visceral organ abscesses from May 2014 to April 2016 requiring hospitalisation in Changi General Hospital was conducted. A total of 140 adult patients with KP visceral organ abscesses were identified. The commonest site of involvement was the liver (77.9%), followed by genitourinary tract (20.7%). Diabetic patients were more likely to have liver abscesses, genitourinary abscesses, abscesses in 2 or more organs, genitourinary disease with abscess formation outside of the genitourinary tract, and endovascular infection. Patients with extended spectrum beta-lactamase producing KP, were more likely to have an obstructive lesion related to the site of the abscess. Overall mortality rate was 7.1%. Amongst survivors, the mean total duration of parenteral antimicrobial therapy was 2.5 weeks before switching to oral antimicrobial agents. Genitourinary tract is the commonest extra-hepatic site for visceral organ abscess in KP infections. Parenteral to oral switch of antimicrobial agents appears to be a safe and effective treatment option.

Pyogenic liver abscess: a retrospective study of 208 cases in a single surgery department

Introduction: Pyogenic liver abscesses (PLA), a special suppurative infection of the hepatic parenchyma, accounted for 48 percent of visceral abscesses. Among risk factors diabetes mellitus, underlying hepatobiliary or pancreatic disease were identified. Methods: We performed a retrospective study during the period between January 2003 and January 2016. Demographic data, underlying disease, clinical presentation and treatment were analyzed. Results: 208 patients with (PLA) were identified. The mean age was 62,1±17,6 years, 125 patients were male (male to female ratio 1,5:1). The most common presenting sintomatology were fever (88%), followed by abdominal pain (70,7%), nausea (59,8%), anorexia (56,5%) and jaundice (21,7%). Underlying comorbidities like diabetes mellitus, alcoholism, or inmunocompromised (recipient of a liver transplant) were presented in 36,6%, 19,8% and 9,7% respectively. The most common abscess location was the right hepatic lobe (73,9%), followed by the left one (18,5%), being both side located in 7,6%. CT and abdominal US were used in all 208 patients. The average maximum diameter of an abscess was 5,9±3,3 cm. K. pneumoniae was identified in the 20% of the patients in the aspiration culture. Portal vein thrombosis was identified in 9,8% of the patients. Percutaneous drainage (PD) was performed in 131 patients (63%). 15 patients needed surgical intervention because of the underlying cause; in 10 of them a cholecystectomy and surgical drainage was performed, in 3 a laparoscopic drainage, and in one patient a left hepatectomy was required. Conclusions: The mainstay treatment of PLA was PD. K. pneumoniae is an emerging cause of PLA in our region.

Case of Pyogenic Liver Abscesses Caused by Klebsiella Pneumoniae

Liver abscess is a serious intraabdominal infection can be due to result of bacteria, fungi, or parasites infection. Until the end of the last century, pyogenic liver abscesses were predominantly caused by mixed aerobic and anaerobic bacteria, the most frequent isolate being Escherichia coli [1]. Klebsiella pneumoniae (K.pneumoniae) is a known cause of pyogenic liver abscess (PLA) in the absence of hepatobiliary disease. In settings of hepatic infection, it has also been known to cause disseminated infections including meningitis and endopthalmitis. Patients with diabetes mellitus and the preexisting hepatobiliary disease are particularly susceptible to infection as well as those from Southeast Asia [2]. We present a case of Klebsiella liver abscess with bacteremia.