Invasive Liver Abscess Syndrome Research Articles

Liver abscess in the caudate lobe caused by Klebsiella pneumoniae: a rare case report and literature review

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.

Invasive liver abscess syndrome with central nervous system involvement caused by hypermucoviscous Klebsiella pneumoniae: positive string test

Invasive liver abscess syndrome with central nervous system involvement caused by hypermucoviscous Klebsiella pneumoniae: positive string test

鈍的腹部外傷を契機に肝膿瘍破裂を来した侵襲性肝膿瘍症候群の1例(Invasive liver abscess syndrome associated with ruptured liver abscess secondary to blunt abdominal trauma: a case report)

要旨 鈍的腹部外傷を契機に肝膿瘍破裂を来した侵襲性肝膿瘍症候群の症例を経験した。症例は70歳代の男性で運転中の一過性意識障害により，事故を起こした。CT検査で肝S5深部からS6に造影剤血管外漏出像を伴う日本外傷学会肝損傷分類IIIb型の肝損傷と診断した。緊急動脈塞栓術を施行し止血を得たが，血液検査でCRP 20.68mg/dLと高値であった。第2病日に体温38.5℃の発熱を認め，感染症の合併を疑い，各種培養を採取し抗菌薬を開始した。第4病日に過粘稠性Klebsiella pneumoniaeが検出され，第5病日にCT検査を再検したところ肝S6に肝膿瘍を認めた。受傷後から右季肋部痛が出現し，後方視的に検討すると来院時のCT画像で肝膿瘍破裂の所見を認めたことから，肝膿瘍による敗血症が先行し鈍的腹部外傷を契機に肝膿瘍破裂を来したと判断した。第9病日に経皮的ドレナージ，第14病日に腹腔鏡下洗浄ドレナージを施行した。第23病日にCRP 17.0mg/dLと再上昇を認め，CT検査を再検したところ，胸腰椎移行部に傍椎体膿瘍を認め，侵襲性肝膿瘍症候群による転移性病変と考えた。肝膿瘍破裂は早期ドレナージが重要であり，鈍的肝損傷の診療において，炎症反応高値と非典型的な画像所見を認めた際には肝膿瘍破裂を疑い治療を進める必要がある。

Liver, lung, muscle, and bone: Klebsiella pneumoniae invasive liver abscess syndrome in a Vietnamese immigrant

Liver, lung, muscle, and bone: Klebsiella pneumoniae invasive liver abscess syndrome in a Vietnamese immigrant

Clinical characteristics and manifestations in patients with hypermucoviscous Klebsiella pneumoniae bacteremia from extra-hepatobiliary tract infection.

Hypermucoviscous strains of Klebsiella pneumoniae (KP) are associated with invasive liver abscess syndrome. However, little is known about the characteristics of this phenotype in non-hepatobiliary infections. In this study, we investigated the clinical characteristics of patients with hypermucoviscous Kp (hmvKp) bacteremia from non-hepatobiliary tract infection. This retrospective cohort study was implemented at Samsung Changwon Hospital. From March 2018 to December 2019, adult patients (≥ 18years) with KP bacteremia of the extra-hepatobiliary system were enrolled. Hypermucoviscosity was defined by the string test. Clinical characteristics and 30-day all-cause mortality between patients with hmvKp and non-hmvKp bacteremia were compared. Among 179 cases of non-hepatobiliary KP bacteremia, 67 (37.4%) and 112 (62.6%) isolates were classified as hmvKp and non-hmvKp, respectively. In the hmvKp group, metastatic infection (9.0 vs. 1.8%, P = 0.054) and purulent or necrotizing infection (31.3 vs. 9.8%, P < 0.001) were more frequently observed. Additionally, non-hmvKp had more frequent resistance to cefotaxime (11.9 vs. 38.4%, P < 0.001). Thirty-day all-cause mortality was similar in the hmvKp (41.8%) and non-hmvKp (39.3%) groups (P = 0.643). In multivariable analysis, septic shock (adjusted hazard ratio [aHR] = 3.05, 95% confidence interval [CI]: 1.22-7.63) and Pitt bacteremia score (aHR = 1.23 per 1 point, 95% CI 1.14-1.33) were associated with increased mortality in patients with Kp bacteremia, while urinary-tract infection (aHR = 0.38, 95% CI 0.18-0.76) was associated with decreased mortality. hmvKp was associated with less frequent drug resistance and metastatic-purulent presentation in non-hepatobiliary infection like in hepatobiliary infection. However, hmvKp was not associated with clinical outcomes.

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).

S3051 Invasive Liver Abscess Syndrome Leading to Klebsiella Endophthalmitis - A Possibly Reversible Debilitating Disease?

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.

S3215 Treatment of Invasive Liver Abscess Syndrome With Limited Percutaneous Drainage and Antibiotics

S3215 Treatment of Invasive Liver Abscess Syndrome With Limited Percutaneous Drainage and Antibiotics

Klebsiella invasive liver abscess syndrome presenting with a central nervous system manifestation secondary to latent cholecystitis: a case report

BackgroundBrain abscess is a life-threatening event. Moreover, when Klebsiella pneumoniae is the cause, rapid diagnosis and appropriate treatment are required. Klebsiella invasive liver abscess syndrome, a bloodstream metastatic infection of potentially aggressive nature, has been recognized to cause infection in the central nervous system, and concern for Klebsiella liver abscess syndrome is increasing globally.Case presentationA 73-year-old Japanese woman was admitted to the institution complaining of aggravated dysarthria and weakness in the right upper extremities with onset 5 days earlier. Magnetic resonance imaging revealed a brain abscess in the left basal ganglia, and abdominal computed tomography revealed a liver abscess in liver segment 7. The patient’s dysarthria symptoms became increasingly worse over the next few days, so surgical drainage via frontotemporal craniotomy was performed on admission day 3, and subsequent culture from the brain abscess showed growth of Klebsiella pneumoniae. On admission day 9, percutaneous transhepatic drainage of the liver segment 7 abscess was undertaken. The pus culture also showed growth of Klebsiella pneumoniae, thus associating the liver abscess with the brain abscess. Following long-term conservative treatment with antibiotics and abscess drainage, the liver abscess disappeared. However, the patient continuously presented with right upper quadrant pain, and abdominal computed tomography showed swelling of the gallbladder. Consequently, percutaneous transhepatic gallbladder drainage was initially administered, and the bile culture was also positive for Klebsiella pneumoniae. For radical treatment, a laparoscopic cholecystectomy was performed on admission day 99. The postoperative period was complicated by an intraabdominal abscess; however, conservative therapy was successful. She was subsequently discharged, and 12-month follow-up revealed no further sequelae.ConclusionsWe describe a rare case of Klebsiella liver abscess syndrome, which first presented with a central nervous system manifestation. Our patient was successfully treated via an early surgical intervention and subsequent antibiotic therapy. Although surgical drainage remains the cornerstone treatment for brain abscess, when a brain abscess is found, and there is a high index of suspicion for the existence of a liver abscess, Klebsiella liver abscess syndrome should be considered as a possible diagnosis.

A Case of Invasive Liver Abscess Syndrome Encountered at a Hospital with a Limited Capacity to Perform Tests

A Case of Invasive Liver Abscess Syndrome Encountered at a Hospital with a Limited Capacity to Perform Tests

1247. Molecular Epidemiology of Multi-drug Resistant Klebsiella pneumoniae and K. quasipneumoniae in Qatar

BackgroundThe molecular epidemiology of carbapenem-resistant Klebsiella species is not well investigated in Qatar. The objective of this work was to characterize the genetic context of carbapenemase-producing Klebsiella isolates recovered from clinical specimens.Methods Klebsiella isolates (n=100) were collected at 7 tertiary hospitals from 2015-2017. Identification and susceptibility testing were performed using MALDI-TOF MS and BD Phoenix system, respectively. Whole Genome Sequencing was performed on the Illumina NextSeq platform. Phylogenomic analysis, screening of resistance and virulence genes, and comparison of genetic environment of carbapenemase were carried out.Results Klebsiella pneumoniae was common (80), followed by K. quasipneumoniae (16), K. aerogenes (3) and K. oxytoca (1). The most prevalent were genes encoding NDM-1 (39), OXA-48 (20), OXA-232 (10) and OXA-181 (12). KPC-2 (3) and KPC-3 (2) were also identified; no carbapenemase-encoding genes could be identified in 15 isolates. Plasmid locations of 24 carbapenemase-encoding genes were determined; blaNDM-1 was localized on IncFII replicon, while blaOXA-181 and blaOXA-232 were commonly associated with ColKP3 plasmids. pOXA-48-like plasmid was detected in 17/20 isolates harboring blaOXA-48. blaKPC-3 was located on a contig with ‘traditional’ Tn4401a mobile genetic element. Sequence types (STs) were diverse and the ‘traditional’ clonal group (CG) 258 was rare. K. pneumoniae ST147 was predominant (13), followed by ST231 (7) and ST11 (5). Nine K. quasipneumoniae isolates belonged to ST196 and were highly clonal. The virulence loci such as yersiniabactin (ybt) and rmpA were not detected within the study’s K. quasipneumoniae isolates. Amongst K. pneumoniae, there were 50 ybt+ isolates; 8 isolates had rmpA, and of these, 3 belonged to ST383. K. pneumoniae serotype K2, the capsular serotype associated with invasive liver abscess syndrome, was detected in 5 isolates. Genetic relationship of carbapenem-resistant Klebsiella pneumoniae and K. quasipneumoniae isolates in Qatar inferred from core genome SNPs. The tree is overlaid with predicted antimicrobial resistance genes and virulence factors for each isolate.ConclusionThe predominant carbapenemases among clinical Klebsiella species isolates in Qatar are NDM and OXA-48 like enzymes, disseminated through various plasmids. The detection of carbapenemase-producing isolate bearing rmpA and serotype K2 reflect the presence of both multidrug resistance and hypervirulence in K. pneumoniae.Disclosures Yohei Doi, MD, PhD, AstraZeneca (Speaker’s Bureau)bioMerieux (Consultant)FujiFilm (Advisor or Review Panel member, Speaker’s Bureau)Gilead (Consultant)GSK (Consultant)Meiji (Consultant)MSD (Consultant)Shionogi (Consultant) Yohei Doi, MD, PhD, Astellas (Individual(s) Involved: Self): Grant/Research Support; AstraZeneca (Individual(s) Involved: Self): Speakers’ bureau; bioMerieux (Individual(s) Involved: Self): Consultant, Speakers’ bureau; Chugai (Individual(s) Involved: Self): Consultant; Entasis (Individual(s) Involved: Self): Consultant; FujiFilm (Individual(s) Involved: Self): Advisor or Review Panel member; Gilead (Individual(s) Involved: Self): Consultant; GSK (Individual(s) Involved: Self): Consultant; Kanto Chemical (Individual(s) Involved: Self): Grant/Research Support; MSD (Individual(s) Involved: Self): Speaking Fee; Pfizer (Individual(s) Involved: Self): Grant/Research Support; Shionogi (Individual(s) Involved: Self): Grant/Research Support, Speakers’ bureau; Teijin Healthcare (Individual(s) Involved: Self): Speakers’ bureau; VenatoRx (Individual(s) Involved: Self): Consultant

Klebsiella pneumoniae-related invasive liver abscess syndrome complicated by purulent meningitis: a review of the literature and description of three cases

BackgroundKlebsiella pneumoniae (K. pneumoniae) invasive liver abscess syndrome (ILAS) with purulent meningitis was rarely identified the mainland of China. Last winter, we received 3 cases of K. pneumoniae meningitis and all of them died in a short time. We report these cases in order to find the reason of high mortality and discuss effective effort to improve these patients’ prognosis.Case presentationThree patients with uncontrolled diabetes developed live abscess and purulent meningitis. Upon admission, the clinical manifestations, laboratory result of blood and cerebrospinal fluid (CSF) and imaging examinations were compatible with K. pneumoniae ILAS which had metastasis infection of meningitis. Even with timely adequate antibiotic therapy and strict glycemic control, all of the patients’ condition deteriorated rapidly and died in a short time.ConclusionThe reason of patients’ poor prognosis might be the absence of liver abscess drainage, high level of CSF protein which indicates severe inflammation and unknown special but stronger virulence factors of K. pneumoniae the patients’ living place Zhangjiakou. Strict glycemic control, early drainage of liver abscess and appropriate antibiotic application are recommended for treating this condition, further progress on the pathogenesis and treatment of K. pneumoniae meningitis may help patients gain a better prognosis.

Invasive liver abscess syndrome caused by Klebsiella pneumoniae, case series

Primary liver abscesses caused by Klebsiella pneumoniae and their related systemic complications produce the invasive liver abscess syndrome due to Klebsiella pneumoniae. To describe the clinical, epidemiological and evolution characteristics in our center. A retrospective cohort of hospitalized adults in Hospital Italiano de Buenos Aires between January 1st, 2001 and May 1st, 2020. We included patients with diagnosis of abscess in any organ with rescue in culture or positive blood culture for Klebsiella pneumoniae. Epidemiological, clinical characteristics and prognosis of those with hepatic primary localization were analyzed. 10 patients were included. Two (20%) patients were Oriental. Median age was 69 years (interquartile range 64-79), nine (90%) were men. The most frequent comorbidity was type 2 diabetes (40%). Four (40%) patients had spread to other organs. The median hospitalization was 21.5 days (IIC 15-43), 60% (n: 6) were hospitalized in the intensive care unit and 30% (n: 3) died. The invasive liver abscess syndrome due to Klebsiella pneumoniae is a rare life-threatening disease. Our study reports the characteristics of patients with this syndrome in our population.

当院におけるinvasive liver abscess syndrome 4例の視力についての検討(Eyesight of invasive liver abscess syndrome: a report of four cases)

要旨 近年Klebsiella pneumoniaeによる原発性肝膿瘍に転移性感染巣を合併した病態，いわゆるinvasive liver abscess syndrome（ILAS）が報告されている。転移巣としては髄膜炎や眼内炎，脳膿瘍があり，早期に治療介入しなければ予後は不良である。今回ILASの4例を経験したため報告する。2011年から2017年までに当院でILASと診断した4症例であり，年齢は64歳から88歳で，いずれも市中感染であった。転移巣としては眼内炎のほか，髄膜炎が多く認められた。4例のうち1例は敗血症による多臓器不全で死亡した。4例とも眼内炎を併発しており，うち3例は治療介入したものの失明に至ったが，早期に治療介入した1例は視力を温存でき，かつ中枢神経障害を残さず治療し得た。ILASと診断し，早期発見と治療開始により失明に至ることなく治療した症例を経験した。眼内炎併発例においても，初診時に比較的視力が良好な場合には失明を免れる可能性がより高い。そのため，肝膿瘍患者，特に併存症に糖尿病のある者では，培養結果を待たずに，Klebsiella pneumoniaeによる同病態を鑑別に挙げ，眼底検査を含めた積極的な転移性感染巣の検索を行い，治療を開始する必要がある。

敗血症性ショック，多発感染病巣を来した肝膿瘍を伴わない侵襲性過粘稠性クレブシエラ感染症の1例(Hypermucoviscous invasive Klebsiella pneumoniae syndrome without liver abscess with septic shock and multiple infection: a case report)

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。

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.

INVASIVE LIVER ABSCESS SYNDROME AS A CONSEQUENCE OF KLEBSIELLA PNEUMONIAE URINARY TRACT INFECTION IN A NONDIABETIC AMERICAN CAUCASIAN MALE: A CASE REPORT

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Invasive K. pneumoniae pyogenic liver abscess (KPPLA) is a condition documented primarily in Southeast Asian populations with concurrent diabetes as a predisposing factor.1 Recent literature has noted the occurrence of KPPLA in non-diabetic populations primarily in Europe and Australia.3 We present a unique case of KPPLA in a Caucasian nondiabetic patient presenting at our teaching institution. CASE PRESENTATION: A 69-year-old male with a history of hypertension presented to our Emergency Department (ED) with 4 days of severe low back pain, chills, fatigue, oliguria, and anorexia. On initial presentation, he was tachycardic, febrile and hypotensive. Initial laboratory evaluation was suggestive of septic shock and transaminitis, with computer tomography (CT) imaging revealing gallbladder sludge, presumed to be the infectious source. He was treated with aggressive fluid resuscitation, vasopressor support, and empiric broad spectrum antibiotic therapy. Continued clinical deterioration prompted repeat imaging. An abdominal CT revealed a 9.5 x 6.9 cm left hepatic abscess, which was confirmed on Magnetic Resonance Imaging (MRI). A percutaneous drain was placed and subsequent culture of the fluid confirmed the presence of Klebsiella pneumoniae, which was also grown in the urine and blood cultures. It was felt that a urinary tract infection (UTI) with hematogenous seeding of the liver and subsequent abscess development was the likely etiology of this patient’s findings. After clinical improvement, he was discharged on intravenous antibiotic therapy. There was resolution of the abscess after 6 weeks of therapy. DISCUSSION: Klebsiella pneumoniae is a virulent gram negative rod involved in the pathogenesis of PLA with up to 60% of reported cases occurring in Southeast Asia.2 Important risk factors for disease development include: Asian ethnicity, antibiotic use, impaired fasting blood glucose and diabetes.2 Pathogen virulence factors include: K1 serotype, mapA gene positivity and mucous hyperviscosity.3 Patients with KPPLA commonly present with fever, nausea, vomiting, and right upper quadrant tenderness, with virulence ranging from a single microbial abscess syndrome to multiorgan septic metastasis. Characteristic findings on abdominal CT include a single thin-walled multiseptate mass with a necrotic center.3 Treatment strategy revolves around broad gram negative coverage in addition to abscess drainage. First line therapy includes piperacillin-tazobactam or alternatively, ceftriaxone with metronidazole.3 CONCLUSIONS: Early identification and treatment can dramatically improve outcomes in this high-mortality condition. We present a unique case of KPPLA in a non-diabetic caucasian male observed at our teaching institution. Reference #1: 1. Al-khazraji A, Alkhawam H, Garrido B. “ID: 29: Invasive Liver Abscess Syndrome in North America.” Journal of Investigative Medicine 2016;64:938-939. Reference #2: 2. Kamal F, Williams G, Akbar H, Khan MA, Kadaria D. Klebsiella Pneumoniae Liver Abscess: a Case Report and Review of Literature. Cureus. 2017;9(1):e970. Published 2017 Jan 10. https://doi.org/10.7759/cureus.970 Reference #3: 3. Maybury B, Powell-Chandler A, Kumar/Ann N. “Two cases of Klebisella pneumoniae liver abscess necessitating liver resection for effective treatment.” R Coll Surg Engl. 2015 Apr; 97(3): e37-e38. DISCLOSURES: No relevant relationships by Kashif Hussain, source=Web Response Speaker/Speaker's Bureau relationship with Abbvie Please note: $1001 - $5000 Added 03/15/2019 by Heidi Roppelt, source=Web Response, value=Salary No relevant relationships by David Rovello, source=Web Response No relevant relationships by Liana Tatarian, source=Web Response No relevant relationships by Daisy Young, source=Web Response

3197 Pyogenic Liver Abscess in B-Thalassemia: A Case Report

INTRODUCTION: Pyogenic liver abscess typically develops via systemic seeding of an infection or from biliary disease through direct spread or portal circulation. Invasive liver abscess though may occur in Beta-thalassemia major patients are a rarity in Beta-thalassemia minor. CASE DESCRIPTION/METHODS: 36-year-old woman with a history of B-thalassemia minor presents to the ED with complaints of acute onset severe, non-radiating right upper quadrant pain. She endorses fevers, chills and night sweats but denied anorexia, nausea, vomiting, diarrhea or urinary symptoms. Never been transfused. Physical exam was pertinent for a temperature of 102.8 F, tachycardia of 138 bpm, and an upper quadrant abdominal tenderness with some guarding. Labs was notable for leukocytosis with neutrophil predominant, anemia with Hb of 5.3 g/dl. Elevated ESR and CRP. Lipase and amylase were normal. CT abdomen showed 10.3 cm thick-walled, complex fluid collection in the right hepatic lobe and splenic abscesses consistent with a pyogenic abscess. Blood cultures were negative. She was started on empiric antibiotic with vancomycin and piperacillin/ tazobactam and was subsequently taken to interventional radiology for drainage of the abscess, with a J-P drain left insitu. The patient received 2 units of packed red blood cells. Fluid culture from drain was positive for Klebsiella pneumoniae which was sensitive to Levaquin. The patient's condition improved while on antibiotics with subsequent removal of the J-P drain. She was successfully discharged on oral Flagyl and Levaquin for 14 days. DISCUSSION: Typically, thalassemia minor carriers are clinically asymptomatic with very little to no complications. Infections however, are a major complication, and constitute the second most common cause of mortality and a main cause of morbidity in patients with thalassemia. The major culprit bacterial infections in thalassemia patients are Klebsiella sppand Yersinia enterocolitica. K. pneumoniae is also associated with a community-acquired primary invasive liver abscess syndrome. Liver abscess occur more commonly in beta- thalassemia major as these group of patient have predisposing factors such as underlying hepatobiliary dysfunction and recurrent transfusions. This condition is rare in beta- thalassemia minor. Abscess rupture is a rare complication, while metastatic infection to other sites can occur. Diagnosis is usually made with CT scan of the abdomen while treatment is should be started with empiric broad-spectrum and drainage of the abscess.

Klebsiella pneumoniae and Klebsiella quasipneumoniae define the population structure of blaKPC-2Klebsiella: a 5 year retrospective genomic study in Singapore.

To describe the population structure, molecular epidemiology and genetic context of blaKPC-2-bearing Klebsiella pneumoniae. Isolates (n = 157) were retrospective, phenotypically carbapenem-resistant blaKPC-positive K. pneumoniae, collected from public hospitals. WGS was performed on the Illumina platform. Phylogenomic analysis, screening of resistance and virulence genes, and comparison of the genetic environment of blaKPC were carried out. Based on core-tree phylogeny, 67.5% of the isolates were K. pneumoniae and the remainder comprised Klebsiella quasipneumoniae. No Klebsiella variicola strains were observed. Only a single K. pneumoniae carbapenemase (KPC) variant type, blaKPC-2, was seen. MLSTs were diverse and did not comprise the 'traditional' KPC clonal group (CG) 258. blaKPC-2 was associated with a non-Tn4401 element (NTE) in >99% of genomes. Screening for four key virulence loci: yersiniabactin (ybt), aerobactin (iuc), salmochelin (iro) and colibactin (clb) as well as ICEKp (virulence-associated integrative conjugative element of K. pneumoniae), revealed the lack of virulence factors and ICEKp within K. quasipneumoniae. Amongst the K. pneumoniae, there were 32 ybt+ isolates (32/106, 30.2%) and, of these, 8 isolates were also clb+ (7.5%). K. pneumoniae serotypes K1 and K2, the majority of capsular serotype seen in patients with invasive liver abscess syndrome, were detected at 4.5% (7/157). Results suggest that dissemination of blaKPC-2 is driven by NTEKPC in non-ST258 isolates. The detection of blaKPC-2K. pneumoniae serotypes K1/K2 carrying virulence factors, albeit in low numbers, reflects the worrisome convergence of carbapenem resistance and hypervirulence in K. pneumoniae.

Keeping an Eye Out for Klebsiella Endopthalmitis: Klebsiella Pneumoniae Invasive Liver Abscess Syndrome

Hypervirulent Klebsiella pneumoniae strain is a major cause of liver abscess and this bacteria has metastatic properties. This distinct liver abscess syndrome has been increasingly reported in Asia over the past two decades, but is emerging as a global disease. We described an 81-year-old lady, who presented to the emergency department with 1-week prior duration of fever and right eye swelling. She had been admitted for recurrent liver abscess prior to this. Hence, she was initially treated as sepsis secondary to recurrent liver abscess. Meanwhile, she was managed concurrently by ophthalmology team for endophtalmitis. Despite the initiation of treatment with antibiotics, she did not show any improvement and required right eye evisceration to treat the sepsis. Invasive liver abscess syndrome with metastatic endophthalmitis should be screened in patient with Klebsiella liver abscess. They should be monitored for ocular symptoms as early recognition can prohibit delays in treatment, which has debilitating consequences.