JMM Case Reports (2015) DOI 10.1099/jmmcr.0.

000023

Case Report Klebsiella Pneumoniae Liver Abscesses and A

Correspondence
Jenna Gillies
jenna.gillies@ggc.scot.nhs.uk
Received 1 December 2014
Accepted 5 February 2015
Distinct Invasive Syndrome: Case Reports and
Review of The Literature
Jenna Gillies and Teresa Inkster
Department of Microbiology, Glasgow Royal Infirmary, Glasgow, UK
Introduction: Over the past 20 years there has been an increasing awareness of a distinct
invasive clinical syndrome caused by Klebsiella pneumoniae in patients from Asian descent.
Case presentation: Here we report two cases of invasive K.pneumoniae infection in Asian
patients who both presented in Glasgow, UK, with liver abscesses within a 6-month period.
Conclusion: Clinicians should be vigilant for mucoid strains of K. pneumoniae isolated from
patients with liver abscesses of Asian descent and thorough in their investigation for metastatic
complications.
Keywords: hepatic abscess; invasive syndrome; Klebsiella pneumoniae.

Introduction 3.762.4 cm), both felt to be abscesses. Blood cultures taken

Klebsiella pneumoniae is a Gram-negative, oxidase-negative on admission flagged positive after 24 h incubation and a
member of the family Enterobacteriaceae. It is a well- Gram stain revealed Gram-negative rods in both bottles. The
known human nosocomial pathogen and a cause of patient was treated initially with intravenous amoxicillin (1 g
community-acquired urinary tract infections. Recently, a every 6 h), gentamicin (calculated dose) and metronidazole
distinct syndrome has emerged globally, characterized by (500 mg every 8 h). The Gram-negative organism was
liver abscesses and metastatic complications in patients identified as a mucoid lactose fermenter on cystine lactose
from Asian descent presenting from the community electrolyte deficient (CLED) plates and was further identified
(Chang et al., 1988). Detection of specific capsular as a K. pneumoniae (identified by VITEK 2; BioMerieux),
serotypes (K1 and K2) and the presence of a specific gene and ampicillin resistant only. A CT-guided aspirate was
(magA) in K. pneumoniae have been associated with this performed and culture of the aspirate grew a mucoid
invasive syndrome (Turton et al., 2007). We report the first coliform (ampicillin resistant only). Amoebic serology and
two cases, to the best of our knowledge, of K. pneumoniae faecal parasitology were both negative. His clinical course was
invasive syndrome in Scotland, UK, in Asian patients living complicated by a non-ST-segment myocardial infarction and
in Glasgow. acute respiratory distress syndrome. His antibiotics were
escalated to meropenem (1 g three times a day) early in
his admission due to clinical deterioration. He had one
Case report methicillin-resistant Staphylococcus aureus-positive nasal
swab in his first week of admission but subsequently the
Patient 1 screens were negative. He died from multi-organ failure
A 57-year-old man from India but resident in the UK for following a 4-week stay in the intensive care unit (ICU).
7 years, presented with a 2-day history of fever, rigors and The K. pneumoniae isolated from blood cultures was sent
severe right upper-quadrant pain. His only past medical to the Colindale Reference Laboratory (Antimicrobial
history was hypertension. He had travelled to India 3 months Resistance and Healthcare Associated Infections Reference
previously for a 1-month holiday. On initial examination, his Unit, London, UK) and found to be capsular type K1, clonal
heart rate was 105 bpm and he was pyrexial at 38.2 uC. His complex 23 and positive for the magA and wcaG genes.
admission C-reactive protein (CRP) was 216 mg l21 and
white cell count was 11.36106 l21. His urea and creatinine
were within normal limits, as were his liver function tests. A Patient 2
computed tomography (CT) scan revealed two hypodense
lesions in the right lobe of the liver (the largest measuring A 43-year-old man, originally from the Philippines, with
no significant past medical history, was admitted with a
Abbreviations: CLED, cystine lactose electrolyte deficient; CRP, 48 h history of right upper-quadrant pain, rigors and
C-reactive protein; CT, computed tomography; ICU, intensive care unit. hallucinations. He had no significant past medical history.
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J. Gillies and T. Inkster
On examination, his blood pressure was 85/40 mmHg and
his heart rate was 115 bpm. His CRP on admission was
229 mg l21, his white cell count was 10.76106 l21 and
platelets were 826109 l21. His urea and creatinine were
within normal limits. Liver function tests showed a raised
bilirubin 30 mmol l21 (normal range 0–20 mmol l21) and a
raised aspartate transaminase 7 U l21 (normal range 0–
40 U l21) and alkaline phosphatase 94 U l21 (normal
range 0–50 U l21). He was initially treated with intrave-
nous amoxicillin (1 g every 6 h), gentamicin (calculated
dose) and metronidazole (500 mg every 8 h) but became
significantly more hypotensive and was transferred to the
ICU for inotropic support. His antibiotic therapy was
subsequently escalated to intravenous tazocin (4.5 g every
8 h) and gentamicin (calculated dose). Blood cultures
taken on admission were positive for Gram-negative rods
in both bottles after 12 h incubation. An abdomen/pelvis
CT revealed a 664 cm focal lesion in the right lobe of the
liver, initially reported as a haemangioma. Following culture
of a mucoid lactose fermenter on CLED agar, subsequent
identification confirmed K. pneumoniae (VITEK 2), and was
ampicillin resistant only. He was taken for CT-guided
drainage the following day as there was no other obvious
source of a Gram-negative bacteraemia. The pus obtained
also grew a mucoid K. pneumoniae (mucoidity confirmed by
a positive string test and the organism identified by VITEK
2). He required two further procedures to drain the abscess
and the drain was left in situ, and he was required to be on
lavage for several days in order to clear the mucoid collection.
A brain CT was performed to look for evidence of metastatic
infection and showed nothing of note. Similarly, an
ophthalmic examination was normal. He was successfully
discharged from hospital after a 4-week stay.
The K. pneumoniae isolated was sent to the Colindale
Reference Laboratory and found to be capsular type K1,
clonal complex 23 and positive for the magA and wcaG genes.
Discussion
Invasive disease as a result of infection with K1/K2
serotypes of K. pneumoniae has been relatively rare in the
UK (Turton et al., 2007). The Laboratory of Healthcare
Associated Infection, Colindale, UK, detect around 5–10
on average of these isolates per year, although they
detected 14 K1 serotype isolates in 2014. The method
used is multiplex PCR to detect serotype-specific targets
and also capsular type, K. pneumoniae subspecies and
virulence factors (e.g. rmpA and wcaG) (Turton et al.,
2010). The number of these isolates detected may increase
as awareness increases. The prevalence of this syndrome
has been increasing since the late 1980s, and K. pneumoniae
is now the most common cause of liver abscesses in some
Asian countries. To the best of our knowledge, these are
the first cases to be detected in Scotland.
K1 and K2 are the capsular types that display resistance to
phagocytosis, and the rmpA gene is a regulator of the
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mucoid phenotype A (Lin et al., 2004). wcaG is a capsular
fructose synthesis gene. The magA gene has been associated
with the metastatic nature of these infections (Fang et al.,
2004). The association between people of Asian descent
and this syndrome remains unclear. A working hypothesis
based on seroepidemiological studies is that colonization
with the K1 serotype of K. pneumoniae is higher in people
of Asian descent and that the organism may translocate
from the gastrointestinal tract into the hepatic circulation
(Lin et al., 2012).
Most patients present with fever, abdominal pain and
chills. A recognized predisposing risk factor is diabetes
mellitus (around 50 % of cases) (Chan et al., 2007). A
review of studies from the USA, South Korea and Taiwan
revealed that the syndrome predominantly affects men.
The percentage of patients presenting with bacteraemia
varies but ranges from 48 to 74 %. The right lobe of the
liver is the most common site for an abscess (65 %).
Increased CRP, hyperglycaemia and thrombocytopenia are
common at presentation (Siu et al., 2013).
Between 8 and 24 % of patients have a metastatic infection. The
most common sites of metastases are pulmonary, ophthalmic
and the central nervous system (Siu et al., 2013).There is a high
mortality in patients with central nervous system involvement
(Tang et al., 1997) and a poor visual outcome in diabetic
patients with endophthalmitis (Sheu et al., 2011).
Adequate drainage is recommended for the optimal
clinical response. Surprisingly, extended-spectrum b-lacta-
mase producers have not been isolated commonly in this
context, allowing third-generation cephalosporins to be the
mainstay of treatment (Siu et al., 2013). The recommended
duration is 2–4 weeks for an abscess and up to 6 weeks in
the presence of multiple septic emboli (Cheng et al., 2003).
There are no trials at present to support the addition of an
aminoglycoside, although it is likely to be common in
clinical practice (Siu et al., 2013).
The high risk of septic emboli, in particular ocular
involvement, means that detection of this serotype does
alter clinical management. Microbiologists and biomedical
scientists should be vigilant for mucoid (positive string
test) strains of K. pneumoniae isolated from patients with
liver abscesses of Asian descent. Clinicians should be
prompt in aspirating these lesions and thorough in their
investigation for metastatic complications.
Acknowledgements
Dr Jane Turton, Consultant Clinical Scientist, Antimicrobial Resistance
and Healthcare Associated Infections Reference Unit, HPA, Colindale
for help in providing up to date numbers of samples processed.
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