A 58-year-old male of Vietnamese origin with a history of uncontrolled diabetes mellitus was brought to the hospital after being found unresponsive at his home. Physical exam revealed a febrile male with tachycardia and a soft tissue swelling on the anterior part of his left shin. Labs revealed leukocytosis, renal insufficiency, lactic acidosis and elevated liver enzymes. He was intubated for airway protection, started on broad spectrum antibiotics and transferred to the ICU. He underwent an incision and drainage of the shin abscess. Chest radiograph showed possible multifocal pneumonia and CT head was unremarkable. CT abdomen/pelvis showed a right lung empyema and multiple nodular opacities in the liver and lung. Pansensitive Klebsiella pneumoniae grew from his respiratory culture, blood cultures and his leg abscess. An eye exam by ophthalmologist was suggestive of endophthalmitis in his left eye. Lumbar puncture revealed meningitis and an MRI brain showed multiple cerebral micro-abscesses. He was treated with a prolonged intravenous antibiotic course and underwent percutaneous drainage of collections in his liver and chest tube placement in his pleural space. He also received intra-vitreal antibiotics. Patient underwent a tracheostomy but was eventually decannulated. Repeat imaging showed improvement in the size of his liver and lung abscesses. He was discharged to short term rehabilitation center after 6 weeks of hospital stay.
Klebsiella pneumoniae can cause primary liver abscess in the absence of hepatobiliary disease. A minority of patients can develop metastatic infection at other sites and such cases have mostly been described in concurrence with a highly virulent strain in Southeast Asia, particularly in Taiwan. Our patient is of Vietnamese origin but has been a resident of the United States for 36 years. While diabetes increases the chances of Klebsiella infection, it is unclear if it is an independent risk factor for metastatic infection. The highly virulent serotype, K1 has been shown to have a clear association with the development of metastatic disease. While endophthalmitis is the most common manifestation, the brain, the lungs and the liver can also be affected, such as in our patient.
Conclusions:
A minority of patients with primary Klebsiella liver abscess can develop metastatic infections at other sites. It is important to seek out other foci of infection as timely percutaneous drainage and appropriate antibiotics can prevent mortality and morbidity.