SESSION TYPE: Infectious Disease Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Infections with K. pneumoniae are usually hospital-acquired and occur primarily in patients with diminished resistance. Underlying diabetes was significantly more common with community-acquired infection. Compared with K. pneumoniae isolated from patients with primary bacteremia, abscess-forming organisms have a virulent hypermucoviscosity phenotype and may be associated with metastatic infection.
CASE PRESENTATION: 36 years old Chinese male without significant PMH presented to ER with sudden onset of right sided weakness and AMS for about an hour. Had URI like symptoms about a week ago and then noted to have left sided lower extremity discomfort for last 2 days. On arrival to ER, progressive worsening of mental status was noted and head CT scan was normal except air at right globe of eye. On examination, noted to have crepitus on left thigh and X-ray showed subcutaneous emphysema. Primary laboratory showed lactic acid of 9.6 with glucose 733mg%. Insulin drip with IVF was started, and surgery was done, which showed deep intramuscular abscess of about 50cc was drained but no evidence of necrotizing fasciitis. Managed in ICU with Clindamycin and Zosyn , sepsis protocol and required high pressured bi-leveled ventilation for ARDS. Found to have blown pupils with shock the next day which required high dose of pressors. Repeated CT scan of head, chest and abdomen showed multiple cerebral abscesses with pulmonary abscess and ophthalmological exam with ultrasound showed bilateral endophthalmitis with abscess prominent on right side. On the 3rd day of ICU stay complicated with renal failure and required CVVHD and also complicated with DIC and bilateral lower extremities DVT. Blood, sputum, wound and urine cultures all positive for mucoid Klebsiella pneumonae ESBL negative with resistant to piperacillin, sensitive to imipenem and meropenem, antibiotic were changed accordingly. Unfortunately on the 4th day of ICU stay, noted to have diminished in brain steam reflexes, and patient was coded and expired.
DISCUSSION: A distinctive form of tissue-invasive community-associated Klebsiella pneumoniae infection, typified by primary liver abscess and bacteremia, has been well known in Asia for 2 decades. Association of these infections with a hypermucoviscous phenotype was discovered. Reports of invasive K. pneumoniae infections in Western countries are rare. K. pneumoniae soft tissue infections were more likely to have fever, shock, bacteremia, gas formation, pyomyositis, metastatic infections, as well as longer durations of hospitalization
CONCLUSIONS: Our report shows the emergence of hypermucoviscous K. pneumoniae in New York and suggest that it might be unrecognized elsewhere in North America.
1) Tsay RW, Siu LK, Fung CP, Chang FY. Characteristics of bacteremia between community-acquired and nosocomial Klebsiella pneumoniae infection: Arch Intern Med. 2002;162(9):1021
DISCLOSURE: The following authors have nothing to disclose: Thanhtaik Kyaw, Rong Ji
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