Klebsiella pneumoniae K1 Liver Abscess and Septic Endophthalmitis in a U.S. Resident

Abstract

Klebsiella pneumoniae K1 is a major agent of hepatic abscess with metastatic disease in East Asia, with sporadic reports originating elsewhere. We report a case of abscess complicated by septic endophthalmitis caused by a wzyAKpK1-positive Klebsiella strain in a U.S. resident, raising concern for global emergence. CASE REPORTA 58-year-old female resident of Bronx, New York, who was originally from the Dominican Republic presented with a chief complaint of 1 day of decreased vision in her right eye and concomitant symptoms, including weakness, myalgia, low-grade fever, and right upper quadrant pain for 1 week. She had a history of uncomplicated choledochal cyst resection and Roux-en-Y hepaticojejunostomy approximately 5 years prior to presentation but no history of ocular disease or prior intraocular surgery. She reported subsequent travel to the Dominican Republic but denied travel to Asia at any point before or after her surgery. On the initial ophthalmic examination, visual acuity was 20/60 in the affected eye. Slit-lamp examination revealed moderate conjunctival injection in the right eye, along with 4ϩ cells and hypopyon in the anterior chamber. The fundus view was hazy because of opacity in the anterior segment, but the retina was flat. She was diagnosed with presumed endogenous endophthalmitis. Her vision in the affected eye worsened over the next 24 h. Because of right upper quadrant tenderness on examination, further imaging was performed, revealing a hepatic abscess (7 by 7 by 7 cm) (Fig. 1). The patient reported no history of diabetes, and the serum glucose was normal. She was treated with intravenous levofloxacin, and the abscess was drained percutaneously. Cultures of liver aspirate, blood, and urine grew K. pneumoniae susceptible to expandedand broad-spectrum cephalosporins, ampicillin-sulbactam, levofloxacin, aminoglycosides, and trimethoprim-sulfamethoxazole. The isolate exhibited a hypermucoviscous phenotype, as exemplified by a positive string test (Fig. 2). On the seventh hospital day, her ophthalmologic exam deteriorated; she was found to have a subretinal abscess in the peripheral temporal retina, and retinal detachment was noted (Fig. 3). A sample of vitreous fluid was obtained, which revealed polymorphonuclear leukocytes on Gram stain but a negative culture, and intravitreal injection of ceftazidime was performed. Over the next several weeks, the vitreous debris cleared, and the retina more clearly assumed the configuration of a bullous rhegmatogenous detachment stemming from a break related to the retinal necrosis at the site of the subretinal abscess. The patient underwent a vitrectomy for retinal detachment 2 months after her initial presentation. The patient's subsequent course was complicated by a relapse of abdominal pain and an increase in size of the liver abscess following a transition to oral therapy. An abdominal CT scan conducted 2 months after the completion of an 8-week antibiotic course demonstrated resolution of her liver abscess.Because of the similarity of this case to rep...

Analysis of the Bacterial Diversity in Liver Abscess: Differences Between Pyogenic and Amebic Abscesses

“…KC692181), which has been associated with human infections in some liver abscesses. 37,38 The phylogenetic reconstruction separated Bacteroides and Bacteroidetes into two clades ( Figure 2B). The two variants from Bacteroides were detected in the same patient with a pyogenic abscess (N138; clade 1), whereas Bacteroidetes was represented in two groups in the pyogenic abscesses of patients N140 and N117 (clade 2).…”

Loss of Hypermucoviscosity and Increased Fitness Cost in Colistin-Resistant Klebsiella pneumoniae Sequence Type 23 Strains

“…resulting in metastatic complications, including endophthalmitis, meningitis, and cerebral and pulmonary abscesses (24). Serotype K1 is common in HV K. pneumoniae isolates (2), and ST23 strains were found to comprise the majority of serotype K1 K. pneumoniae isolates exhibiting the HV phenotype (25).…”

An Increasing Prominent Disease ofKlebsiella pneumoniaeLiver Abscess: Etiology, Diagnosis, and Treatment

“…A shift from E. coli to K. pneumoniae as the causative pathogen of pyogenic liver abscess may also have occurred in the United States [6–11] and Europe [12–14]. However, differing from the much higher incidence of KLA in Asian countries and areas [1–5] especially the highest incidence in Taiwan that ranges from 80% to 90% [16, 19], a relatively low incidence of 30%–40% is estimated in the US [6, 9].…”

“…Eyes [9, 11, 13, 15, 30, 35, 36, 38], meninges [16, 35], CNS [16, 30], and lungs [9, 13, 16, 30] are the most common metastatic sites. Endophthalmitis is the most common and serious septic complication of KLA, leading to subacute vision impairment.…”

“…Before the 1980s, E. coli was the most common pathogen that caused PLA and was mostly polymicrobial. However, during the past two decades, highly virulent strains of K. pneumoniae had emerged as a predominant cause of PLA in Asian countries and areas [1–5], the United States [6–11], and Europe [12–14], especially Taiwan [2, 15–22], and it tended to spread globally [23–26]. Recent researches have shown, unlike other bacterial-induced PLAs (Non-KLAs) which are mostly associated with biliary tract disorders [19, 27–30], that K. pneumoniae liver abscesses (KLAs) are often cryptogenic [3, 6, 17, 27, 29–34].…”