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A Rare Case of Septic Embolic Pulmonary and Renal Disease Secondary to Hypervirulent Klebsiella pneumoniae From a Lower Extremity Skin Infection FREE TO VIEW

Aleem Surani, MD; David Landman, MD; Sikander Zulqarnain, MD
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SUNY Downstate Medical Center, Brooklyn, NY

Chest. 2015;148(4_MeetingAbstracts):94A. doi:10.1378/chest.2261970
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SESSION TITLE: Chest Infections I Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Septic pulmonary emboli from hypervirulent K. pneumoniae(hv-KP) are rare and mostly associated with infective endocarditis or liver abscess. We present a case of atypical hv-KP leading to hematogenous abscess formation originating from a right leg skin infection.

CASE PRESENTATION: A 44 year old African American female with type 2 diabetes mellitus came to the emergency room with worsening right lower extremity pain and swelling since hitting her leg 7 days ago. She was seen 2 days prior to presentation and given oral cephalexin for presumed cellulitis and returned with worsening cellulits and dyspnea. At triage, she was noted to be in severe sepsis with tachypnea, tachycardia, and a fever to 103.7°F. CT chest showed multiple bilateral perivascular opacities consistent with septic emboli and associated pleural effusion. Initial lower extremity CT showed myositis and cellulitis. CT abdomen showed a 2 cm subcapsular collection suggestive of abscess in the right kidney. Workup including transthoracic, transesophageal, urine, pleural fluid, sputum cultures and AFBs were negative. Because of progressive leg swelling, a repeat CT scan was done 4 days later showing a large abscess anterior to the distal tibia that was surgically drained. Admission blood cultures, as well as abscess cultures grew pan-susceptible KP. She improved with 2 weeks of IV antimicrobials and repeat CT imaging of the chest, kidneys, and lower extremety showed resolving lesions. String test was negative for the hypermucoviscous K. pneumoniae(hmv-KP) phenotype. PCR testing of the KP isolate revealed regulator of mucoid phenotype A(rmpA) gene but not the mucoviscosity-associated gene A(magA) or aerobactin.

DISCUSSION: Hv-KP disease pattern shows a predilection for diabetic patients and can present as systemic (in rare instances pulmonary) septic emboli via hematogenous spread from heptic abscesses. Over 90% of all hv-KP strains possess the iron siderophore aerobactin. Also, this pattern has been strongly associated with hypermucoviscous KP phenotype. Our isolate is not hmv-KP with a pattern of markers not usually associated with hv-KP. We present a new aggressive strain of KP presenting with septic emboli secondary to hematogenous spread from the skin without any cadiac or hepatic involvement requiring prolonged antibiotic course.

CONCLUSIONS: Hypervirulent K. Pneumoniae skin infection should be considered as a source in patients presenting with septic emoblic pulmonary and/or renal disease.

Reference #1: Shon, A. et al. (2013). Hypervirulent (hypermucoviscous) Klebsiella pneumoniae. Virulence,4(2), 107-118.

Reference #2: Nadasy, K. et al. (2007). Invasive Klebsiella pneumoniae Syndrome in North America. Clinical Infectious Disease,45(3), 25-28.

DISCLOSURE: The following authors have nothing to disclose: Aleem Surani, David Landman, Sikander Zulqarnain

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