A 53 year old Chinese female with no PMH presented with 1 week history of nausea, abdominal pain, fever, chills and fatigue. Abdominal pain was not related to food and she denied headache or visual complaints. She is a native of Shanghai, China and moved to the USA 16 years ago. Patient reported history of recent travel to China and Taiwan 3 weeks back. Physical exam was positive for RUQ tenderness without guarding or rigidity. Blood work revealed WBC 8,700/mcl, HB 11.9 g/dl, platelets 25,000/mcl, random glucose 206 g/dl, creatinine 2.09 mg/dl, total bilirubin 2.9 mg/dl, AST 435 IU/L, ALT 676 IU/L, Alk Phos 162 IU/L. RUQ ultrasound was concerning for a liver abscess. CT scan of abdomen showed two 10x9x8 cms confluent abscesses in the right lobe of the liver. Blood and urine culture were sent and patient was started on broad spectrum antibiotics. She underwent IR guided drainage of one of the abscesses and the other abscess cavity failed to yield any pus. Blood, urine and abscess fluid cultures were positive for Klebsiella pneumoniae. On day 2, patient developed hypotension, leukocytosis of 25,000/mcl along with worsening LFTs and thrombocytopenia. She was transferred to a tertiary center and managed by laparotomy, wedge resection and surgical drainage of the abscess. Liver culture was positive for Klebsiella pneumoniae sensitive to cephalosporins. Patient was transitioned to ceftriaxone for total of 8 weeks. 2 months after initial presentation while on IV ceftriaxone she developed acute left shoulder pain with nausea, tachycardia and fever. MRI of shoulder showed concern for septic arthritis. Initially she refused joint fluid aspiration or intervention, but then it was done which showed 443 WBC/cmm and negative crystals. Fluid culture though negative, patient was treated with IV Cefepime for 4 weeks due to preceding history.
Invasive Klebsiella liver abscess (KLA) syndrome is a distinct clinical entity characterized by monomicrobial bacteremia, liver abscess and metastatic infections. It typically affects diabetics and occurs in the absence of hepatobiliary disease. This syndrome occurs predominantly in Southeast Asia especially Taiwan with more recent global occurrence. About 12% of patients develop metastatic complications commonly manifested as endophthalmitis, meningitis or brain abscess. Septic arthritis is a lesser known but possible complication. K1/ K2 capsular strains and hypermucoviscous phenotype contribute to invasive potential. Antibiotic treatment combined with percutaneous drainage of liver abscess is the treatment of choice. Overall outcome is usually favorable but mortality rate up to 11% has been reported.
Awareness of the condition coupled with high index of suspicion is essential for early recognition of KLA syndrome. Prompt treatment is needed to reduce mortality and morbidity particularly when meningitis or endophthalmitis are seen. Constant surveillance for metastatic disease is recommended based on clinical symptoms.
To cite this abstract:Rajagopalan P, Hingorani RV, Patel N. A Classic Case of Invasive Klebsiella Pneumoniae Liver Abscess Syndrome with Metastatic Septic Arthritis. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 748. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/a-classic-case-of-invasive-klebsiella-pneumoniae-liver-abscess-syndrome-with-metastatic-septic-arthritis/. Accessed May 22, 2019.