Case Presentation: A 45 y/o Asian Male from Vietnam with PMH of treated pulmonary tuberculosis 10 years ago upon immigration to the US, presented to the ED with 3-day history of fever, abdominal pain, nausea and vomiting. He denied recent travel or use of antibiotics. On exam he had fever 102.2, tachycardia, scleral icterus and tenderness over RUQ. Initially he had no pulmonary findings and his vision was intact. Labs were significant for leukocytosis of 16,400, Creatinine of 2.3, TBILI of 2.2 and mild transaminitis (AST:ALT ratio 2:1). CT abdomen revealed right hepatic lobe lesion measuring 5.8 x 3.2 cm concerning for an abscess. He was empirically started on vancomycin and piperacillin/tazobactam. Initial blood cultures grew pan-susceptible K. pneumoniae and antibiotics were deescalated to ceftriaxone. Hepatitis panel, HIV, EBV, RMSF, Thyphus and Entamoeba were all negative. Patient underwent right hepatic drain placement by radiology and aspirate grew 4+ the same organism.He became tachypneic with increased O2 requirements and CT Chest showed interval development of a right pleural effusion and was sent to the ICU at which time he began complaining of foreign body sensation in his left eye. Six hours later he developed rapid decrease in his visual acuity; he had new conjunctival injection and was unable to discriminate or count fingers. Bedside ocular US showed no abnormal retinal findings and fluorescein negative for corneal lesions. CT Head was unremarkable. Ophthalmology was consulted and were concerned for diagnosis of EKE. The patient promptly received an intravitreal injection of Ceftazidime within 12 hours of initiation of symptoms. His ocular exam remained stable after intervention. Ceftriaxone was switched to PO Levaquin after clinical improvement to complete a total of 4-6 weeks of therapy per infectious disease recommendations and hepatic drain was removed. Upon discharge patient reported mild improvement in vision, but left eye visual acuity remained 20/100.
Discussion: Endogenous Klebsiella pneumoniae Endophthalmitis (EKE) is a potentially devastating condition rarely seen as a consequence of septic metastatic infection, with higher prevalence among the Southeast Asian population. We present a case of Primary Invasive Klebsiella Liver Abscess (KLA) that rapidly advanced to produce visual impairment and prompted time sensitive action in an attempt to avoid catastrophic visual consequences.Most cases of metastatic infection with KLA have been documented in patients native to East Asia, most commonly manifesting as Endophthalmitis and/or Meningitis. The former has shown an incidence of 12 percent in the largest Taiwanese study and our patient’s geographic origin is likely a major predisposing factor for colonization by organisms with certain virulence factors found in Endophthalmitis patients.
Conclusions: The remarkable fact of this case is that it outlines how imperative it is for clinicians to keep a high degree of clinical suspicion for even the most trivial symptoms such as “feeling dust in the eye.” After initial KLA diagnosis, any sign of ocular involvement should raise concern as the morbidity of Metastatic Endophthalmitis is high even with aggressive therapy and permanent visual impairment or loss can be seen with delays in diagnosis and treatment beyond 24 hours of symptoms onset.