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Chest Infections |

Necrotizing Klebsiella pneumonia

Islam Ibrahim, MD; Mahmoud Abdullah, MBBCh; Hesham Abdelrahman, MBBCh; Ahmed Abdelsalam, MBBCh
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International Medical Center, Jeddah, Saudi Arabia


Chest. 2013;144(4_MeetingAbstracts):216A. doi:10.1378/chest.1704097
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Abstract

SESSION TITLE: Infectious Disease Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Lung abscess are largely caused by gram-negative and anaerobic bacteria, formation of lung abscess secondary to Klebsiella pneumonia had been reported in Asian countries, and attributedt to more virulent strains of Klebsiella bacteria, recently sporadic cases have been reported worldwide, including the United States, the patients are usually immunocompromised, diabetic, it is not typical however for necrotizing Klebsiella pneumonia to affect immunocompetent patients, this case demonstrates an overwhelming Klebsiella pneumonia, leading to respiratory failure, extra pulmonary abscess formation, prolonged fever and sepsis in an immunocompetent patient who was completely healthy prior to his illness in spite of the use of proper and strong antimicrobial therapy, studying the virulence factors of such Klebsiella species may shed some light and lead to the development of modified strategy in combating this organism.

CASE PRESENTATION: 45-year-old Algerian male, college professor, no sign. PMH, presented with prod. cough, fever, SOB & RLL/ LUL consolidation, Temp. 38.5°C, RR 25 , Hr 115 , BP 135/60 mmHg, in respiratory distress, lung exam.RLL bronchial breath sounds with egophony, and inspiratory crackles, rest of exam was normal. O2 sat. 95% on 3 L NC,WBC 18,000, with a left shift, rest of labs were unremarkable.started on ceftriaxone, and azithromycin, He developed rapid respiratory deterioration, repeat CXR showed worsening infiltrates in both lungs, with cavitary lesion in the RLL. O2 sat. 82% on high flow O2. he was intubated, CXR worse with multiple lung abscesses, WBC 32,000 with a left shift. ATB changed to, meropenem, levofloxacin, and vancomycin, sputum cultures grew Klebsiella species, sensitive to meropenem. continued to be febrile, developed hypotension requiring pressors, Levophed, and vasopressin. Empiric anti TB meds were added. liver enzymes elevated, abdomenal CT showed right hepatic lobe abscess. FOB-BAL grew Klebsiella species sensitive to meropenem, BAL negative for AFB, fungus & PCP. The anti TB meds & Vancomycin were discontinued. After 4 weeks in ICU his oxygenation, CXR & hemogdynamics improved. he became afebrile, weaned off mech.vent., & extubated. transferred to the medical ward, underwent extensive physical therapy. The patient got to walk out of the hospital.

DISCUSSION: Lung abscess are usually caused by gram-negative and anaerobic bacteria. Formation of multiple lung abscess secondary to Klebsiella pneumonia in an immunocompetent hosts is rare.Lately more virulent strains have been reported to cause necrotizing pneumonia, with the formation of multiple abscess in Asian countries, more sporadic cases are being reported from various countries around the world including the United States. Although the Klebsiella species show sensitivity to commonly utilized antibiotics, like imipenem, meropenem, Zosyn, and others, the course of the illness is prolonged, and devastating. It can lead to the formation of intra-and extra pulmonary abscess ease, hemodynamic instability, and respiratory failure, as demonstrated in our case. Studying of this cohort may lead to the discovery of new virulent factors that need to be addressed in combating such disease.

CONCLUSIONS: Pneumonia complicated by multiple lung abscesses formation is usually secondary to infection with gram-negative and anaerobic bacteria.Formation of multiple lung abscess secondary to Klebsiella is not a common finding in immunocompetent patients.Sporadic cases of necrotizing Klebsiella pneumonia leading to the formation of intrapulmonary, and extra pulmonary abscess formation have been reported in Asian countries secondary to virulent strains of Klebsiella.Sporadic cases of necrotizing Klebsiella pneumonia are now been reported in various parts of the world.Further studying of the occurrence of such overwhelming and invasive organism may modify the recommendations in the management of such disease.

Reference #1: Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan.Yeh KM, Kurup A, Siu LK, Koh YL, Fung CP, Lin JC, Chen TL, Chang FY, Koh THJ Clin Microbiol. 2007;45(2):466.

Reference #2: Lectinophagocytosis of encapsulated Klebsiella pneumoniae mediated by surface lectins of guinea pig alveolar macrophages and human monocyte-derived macrophages. AU Athamna A, Ofek I, Keisari Y, Markowitz S, Dutton GG, Sharon N Infect Immun. 1991;59(5):1673

DISCLOSURE: The following authors have nothing to disclose: Islam Ibrahim, Mahmoud Abdullah, Hesham Abdelrahman, Ahmed Abdelsalam

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