K2 Serotype Klebsiella pneumoniae Causing a Liver Abscess Associated with Infective Endocarditis

Abstract

Klebsiella pneumoniae primary liver abscess (KPLA) is an emerging disease that is associated with distant septic complications. We report the first case of KPLA associated with infective endocarditis. The K. pneumoniae strain was a hypermucoid K2 serotype carrying the rmpA virulence-associated gene. CASE REPORTA 39-year-old Filipino man without significant past medical history presented to an outside hospital with a 1-week history of fever, chills, and cough, with productive sputum and pleuritic chest pain. He immigrated to the United States 10 years ago. He had recently traveled to the Philippines about 2 months prior to presentation, where he spent 3 weeks. He was found to have bilateral interstitial infiltrates with nodular opacities on his chest X ray, and an ultrasound of the abdomen showed a liver lesion consistent with an abscess. Cefepime and metronidazole were started empirically, and he underwent fine-needle aspiration of the liver abscess by interventional radiology. On the third day after admission, the patient became hypoxic and was intubated. Blood and urine cultures obtained after starting antibiotics were reported as negative, but cultures from the abscess grew Klebsiella pneumoniae resistant to ampicillin but sensitive to all other antibiotics. The patient was subsequently transferred to University Hospital in Newark, NJ, for further management.Upon admission, the patient was febrile (temperature, 101.2°F), tachypneic (respiratory rate, 22 breaths/min), with a heart rate of 96 bpm and blood pressure of 105/68 mm Hg. He was jaundiced and had rales bilaterally on chest auscultation. A 3/6 systolic murmur was heard at the left base with radiation to the axilla. The abdomen was soft, with no significant tenderness, and the rest of the exam was unremarkable. The white blood cell count was 18,300 cells/l with 84% neutrophils; the hemoglobin level was 10.1 g/dl, and the platelet count was 226,000/ l. Liver function tests were normal except for a total bilirubin of 1.8 mg/dl with a direct bilirubin of 0.8 mg/dl. Urinalysis was unremarkable.On the second day after admission, he was noted to have left-eye chemosis, conjunctival hyperemia, and blurry vision, with findings suggestive of endophthalmitis. A transesophageal echocardiogram revealed a large mitral valve vegetation with a new moderate-to-severe mitral regurgitation. Antibiotics were changed to piperacillin-tazobactam and gentamicin. Repeat blood cultures on admission did not yield any growth. A computerized axial tomography scan of the chest and abdomen showed multiple bilateral nodular opacities in the lungs with cavitations in a peripheral distribution consistent with septic emboli and a large multiloculated abscess in the right lower lobe of the liver measuring 6.7 ϫ 7.1 cm.Due to the poor prognosis of Klebsiella endocarditis, the patient underwent mitral valve replacement with a porcine valve on day 6 after admission. Cultures of the papillary muscle grew K. pneumoniae resistant only to ampicillin. To assess for the presence of hypermucovisco...

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