Critical Care: Student/Resident Case Report Poster - Critical Care IV |

Abscess, Abscess Everywhere! A Case of Metastatic Klebsiella Infection FREE TO VIEW

Kevin Dsouza, MD; Kadambari Vijaykumar, MD; Micheal Gurell, MD
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Rochester General Hospital, Rochester, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):446A. doi:10.1016/j.chest.2016.08.459
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Virulent forms of klebsiella pneumoniae have been described in literature, mostly from Taiwan and other Asian countries with predominant ocular, pulmonary, hepatic and cerebral involvement. We describe one such case who presented to the intensive care unit at Rochester General Hospital.

CASE PRESENTATION: A 58 year old Vietnamese gentleman admitted with altered mental status, was found to have septic shock with respiratory failure requiring intubation and intensive care monitoring. Examination was significant for tachycardia and soft tissue swelling on the left anterior shin alone. Initial laboratory studies showed leukocytosis, lactic acidosis and elevated liver enzymes. CT head was unrevealing while chest x-ray showed left midlung airspace disease with bilateral pleural effusions. CSF analysis revealed leukocytosis and elevated protein levels. Patient was started on broad spectrum antibiotics and antiviral medications. Further work up with a CT chest (fig.1) revealed innumerable nodules with a right pleural effusion consistent with metastatic disease. CT abdomen (fig.2) demonstrated multiple nodules in the liver and an exophytic mass in the right kidney indicative of abscesses. Further investigation with MRI brain showed multiple cerebral abscesses while retinal exam was consistent with left sided chorioretinits. At this point, infective endocarditis was considered as a possible source of infection but trans-esophageal echocardiography did not show vegetations. Subsequently, blood cultures grew klebsiella pneumoniae and cultures from incision and drainage of the left anterior shin mass was also positive for klebsiella pneumoniae. He underwent drainage of the liver abscess and right sided empyema and completed a total of 8 weeks of therapy with piperacillin/ tazobactam for metastatic klebsiella infection. Following a prolonged hospital course that included tracheostomy for a short time, patient was discharged to a skilled nursing facility. Six months after initial presentation, the patient is able to live independently at home.

DISCUSSION: Few cases of metastatic klebsiella infection have been reported in literature and the reason for predominance of this syndrome in Asian ethnicity is unknown. Genetic susceptibility plays an important role but infection with virulent K1 strain of klebsiella pneumoniae is implicated in patients with ocular, CNS and liver involvement.

CONCLUSIONS: Our case illustrates metastatic klebsiella infection as an etiology for patients presenting with multi organ septic involvement which is generally associated with a high rate of morbidity and mortality. Increased knowledge about this syndrome especially in a critical care setting would facilitate early diagnosis and treatment.

Reference #1: Sobirk SK, Struve C, Jacobsson SG. Primary Klebsiella pneumoniae Liver Abscess with Metastatic Spread to Lung and Eye, a North-European Case Report of an Emerging Syndrome. Open Microbiol J. 2010; 4:5-7

DISCLOSURE: The following authors have nothing to disclose: Kevin Dsouza, Kadambari Vijaykumar, Micheal Gurell

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