27 Nov 2020

10/19/20: Klebsiella pneumonia and liver abscess

PGY3 Thaer Othman presented a case of a 55 y/o male wit history of Type II DM presents with cough x3 days and diarrhea x 1 week.  Patient reports diarrhea began 1 week ago, watery, yellow in color, non-bloody.  The diarrhea was 3-5 times per day until he presented to outside clinic where he received 2 IM injections with improvement in symptoms.  Starting 3 days prior to admission, the patient began to have persistent cough with maroon sputum, as well as intermittent fevers and chills.  Patient reports recent weight loss over the past week, unclear how much.  He otherwise denies sick contact or recent travel.

Vital signs: T 36.7C, HR 96, BP 126/76, SpO2 96% RA

Physical Exam significant for mild scleral icterus, normal cardiac exam, coarse breath sounds throughout pulm exam, no jaundice noted on the skin, and abdomen soft, nontender to palpation.

CBC: WBC 19.4 > Hb 12.7/Hct 36.1 <Plt 147

Diff: 84.8% PMN, 6% lymph, 8.5% monocytes, 0.3% eosinophils, 0.4% basophils

CMP:

Na 129/K 3.4/Cl 88/HCO3 26/BUN 13/Cr 0.55 <Glucose 301

ALP 116>T.protein 5.9/Albumin 2.4/AST 35/ALT 35/Tbili 10.2/Dbili 8.2

Coags: PT 15.1, INR 1.21

CXR showed innumerable lung nodules and consolidative opacities within the lungs, bilaterally.

Malignancy workup done with was negative for all the cancer markers.

Infectious workup done with negative results for the flu panel, RSV, HIV, acute hepatitis panel, urine legionella, stool culture, blood culture and fungal studies.  Sputum culture resulted with 3+ Klebsiella pneumoniae.  Bronchoscopy done with similar results.

Abd US done significant for 3.4cm heterogeneous isoechoic mass in the R lobe of the liver.

CT Chest/Abdomen/Pelvis showed extensive large nodular consolidative opacities with adjacent ground-glass attenuation throughout all lobes of both lungs, right greater than left.  There is also an irregular 5.3cm region of hypoattenuation in the anterior right hepatic lobe that is of uncertain etiology.  Multiple prominent mediastinal lymph nodes.

Treatment: Patient started on IV Ceftriaxone.  Ophtho exam done and was unremarkable.  He was discharged to complete a 4 week course of Ceftriaxone.  Due to the patient’s southeast Asian ethnicity, there was high consideration of the K1 serovar variety of Klebsiella pneumoniae.

Take home points:

  1. The K1 predominant serotype can cause bacteremia, liver abscess and septic endophthalmitis.
  2. Risk factors include diabetes mellitus, alcoholism, malignancy, COPD and glucocorticoid therapy.
  3. Treatment: 4-6 weeks of IV antibiotics (3rd generation cephalosporin)

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