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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 34  |  Issue : 3  |  Page : 133-136

Recurrent serotype K1 Klebsiella pneumoniae liver abscess: A single or different pathogen?


1 Department of Otolaryngology-Head and Neck Surgery, Division of Infectious Diseases and Tropical Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Taichung Armed Forces General Hospital, Taichung, Republic of China
2 Department of Internal Medicine, Division of Infectious Diseases and Tropical Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Date of Submission14-May-2013
Date of Decision04-Sep-2013
Date of Acceptance25-Sep-2013
Date of Web Publication12-Jun-2014

Correspondence Address:
Assoc. Prof. Jung-Chung Lin
Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Sec. 2, Cheng-Gong Road, Taipei 114, Taiwan
Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1011-4564.134406

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  Abstract 

We report a case of an 81-year-old woman who had a history of type 2 diabetes mellitus with the presentation of a recurrent community-acquired liver abscess caused by capsular serotype K1 Klebsiella pneumoniae after a previous liver abscess had been cured. With regards to the serotype K1 K. pneumoniae strains, the molecular genome of the recurrent strain differed completely from the strain that had caused the primary community-acquired liver abscess even though the antibiogram was the same. This case attempts to highlight that capsular serotype K1 could be an important factor influencing liver abscess formation and its subsequent recurrence.

Keywords: Klebsiella pneumoniae, recurrence, liver abscess, serotype K1


How to cite this article:
Lai WS, Lin JC. Recurrent serotype K1 Klebsiella pneumoniae liver abscess: A single or different pathogen?. J Med Sci 2014;34:133-6

How to cite this URL:
Lai WS, Lin JC. Recurrent serotype K1 Klebsiella pneumoniae liver abscess: A single or different pathogen?. J Med Sci [serial online] 2014 [cited 2019 Sep 15];34:133-6. Available from: http://www.jmedscindmc.com/text.asp?2014/34/3/133/134406


  Introduction Top


The epidemiology, management, and mortality in patients with pyogenic liver abscess, a potentially life-threatening intra-abdominal infection, have changed dramatically over the last two decades. In the past, Escherichia coli was the predominant causative agent. However, recent reports indicate that the incidence of Klebsiella pneumoniae has surpassed that of E. coli in Asia and western countries. The early use of broad-spectrum antibiotics plus drainage is the gold standard to control morbidity and mortality. [1],[2],[3],[4]

A recurrent K. pneumoniae liver abscess (KLA) has seldom been reported, [5],[6] and a recurrent liver abscess with the same pathogen, but different molecular pattern even less so. Herein, we describe a case of a liver abscess caused first by K. pneumoniae, and then unusually a recurrent liver abscess 4 months later caused again by K. pneumonia in which the strain shared the same capsular serotype and antibiogram with the first K. pneumoniae strain.


  Case Report Top


An 81-year-old woman presented with a history of type 2 diabetes mellitus and hypertension, which had been controlled by regular oral medications for >10 years. Her first admission to our department was on May 30, 2010, because of poor appetite and general malaise for 1-week. At the emergency department, laboratory examinations showed leukocytosis and elevated C-reactive protein. Accordingly, abdominal ultrasonography was performed, which disclosed multiple hypoechoic lesions over the inferior portion of the lateral segment (S3), medial segment of the left hepatic lobe (S4) and inferior portion of the anterior segment of the right hepatic lobe (S5), which were seen as multi-lobulated cystic lesions on abdominal computed tomography, with the largest being about 5 cm × 2 cm in size over segment 4 [Figure 1]. Mild anemia and positive stool occult blood test were also noted. A liver abscess was confirmed by fine needle aspiration with pinkish pus from the hepatic lesions. She was treated with percutaneous transhepatic abscess drainage and parenteral antibiotics with third generation cephalosporin during hospitalization. The drained abscess culture showed serotype K1 K. pneumoniae with positive magA and rmpA genes on June 6, 2010, which was susceptible to the antibiotics we had administered. After discharge, an oral antibiotic regimen was employed for a total of 4 weeks. One month after discharge, follow-up abdominal sonography showed no focal lesions of the liver parenchyma [Figure 2].
Figure 1: Abdominal computed tomography at the first admission revealed multiple multi-loculated cystic lesions over S3, S4 and S5

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Figure 2: Following-up abdominal sonography showed no focal lesions of the liver parenchyma

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Unexpectedly, the patient developed another episode of a liver abscess in the following 3 months. She presented with intermittent fever with chills and fatigue for 5 days, and visited our emergency department again on October 3, 2010. Complete blood count showed more severe leukocytosis and a higher level of C-reactive protein than during the previous admission, and a positive stool occult blood test was also noted. Abdominal ultrasonography and noncontrast abdominal computed tomography both disclosed an irregular hypoechoic lesion (size: About 4.2 cm) over the superior portion of the anterior segment of the right hepatic lobe (S8), which was different from the first episode [Figure 3]. A liver abscess was diagnosed by fine needle aspiration of the S8 lesion. An aspirated pus culture showed E. coli, however blood cultures revealed ampicillin-resistant serotype K1 K. pneumoniae positive for the magA and rmpA genes, but with a different type of pulse-field gel electrophoresis [Figure 4]. The patient then received 4 weeks of antibiotic treatment, after which no complications including metastatic foci infection of the endophthalmitis or brain abscess were noted from the recurrent liver abscess. The characteristics and demographic data of the primary and recurrent KLA are shown in [Table 1].
Figure 3: The secondary admission showed an irregular hypoechoic lesion over the S8 segment by abdominal ultrasonography (a) and abdominal computed tomography (b)

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Figure 4: Strains of capsular serotype K1 primary Klebsiella pneumoniae liver abscess (KLA) and recurrent KLA showed different molecular patterns in pulsed field gel electrophoresis (P: first primary KLA, R: recurrent KLA, M: Marker)

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Table 1: The characteristics and demographic data of primary and recurrent Klebsiella pneumoniae liver abscess

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  Discussion Top


A pyogenic liver abscess may be caused by hematogenous dissemination or via the portal vein from a gastrointestinal infection by disseminated sepsis. [7] The disease can also arise from surgical or penetrating wounds and occasionally tissue super-infections. The pathogenesis leading to a major liver abscess is polymicrobial, and mixed enteric facultative and anaerobic pathogens are the most common. The typical clinical manifestations are fever, abdominal pain, nausea, vomiting, anorexia, and malaise, however these are nonspecific. In the current report, the antibiogram of the recurrent K1 KLA strain remained uniquely resistant to ampicillin, which was the same as the strain of the primary K1 KLA. From the view point of the genome, a different molecular pattern was demonstrated between the primary KLA and the recurrent strain. The most probable explanation why K. pneumoniae lead to the recurrent liver abscess is that it had colonized the intestinal tract or previously been seeded on the portal venous system.

Community-acquired pyogenic liver abscesses caused by K. pneumoniae has become an important health issue in Taiwan and the USA. One report indicated that the annual incidence of pyogenic liver abscesses has increased steadily from 11.15/100,000 population in 1996 to 17.59/100,000 in 2004. [8] Risk factors include diabetes mellitus, gastrointestinal malignancy, hepato-biliary pathology and renal diseases. In one case-control study, patients with diabetes had a 3.6-fold increased risk of experiencing a pyogenic liver abscess. [9] Abscesses caused by K. pneumoniae have been reported to be more strongly associated with diabetes or impaired fasting glucose than liver abscesses caused by non-K. pneumoniae. [10]

Poor glycemic control with a higher level of glycosylated hemoglobin A1c leads to a higher risk of KLA and recurrent liver abscesses. We assume that diabetes mellitus is also a risk factor for recurrence. However, recurrent liver abscesses have been reported to occur in different hepatic segments resulting from common pathogens with K. pneumoniae. [11] Good glycemic control can increase the ability of neutrophil phagocytosis and prevent recurrent pyogenic liver abscesses.


  Conclusion Top


Serotype K1 K. pneumoniae more easily causes liver abscesses and thus recurrence, especially in patients with diabetes and poor glycemic control.


  Acknowledgments Top


This work was supported by grants from Tri-Service General Hospital, National Defense Medical Center (C03-01 and C03-02), Taiwan.


  Disclosure Top


The authors have no financial conflicts of interest.

 
  References Top

1.Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: Recent trends in etiology and mortality. Clin Infect Dis 2004;39:1654-9.  Back to cited text no. 1
    
2.Kim JK, Chung DR, Wie SH, Yoo JH, Park SW, Korean Study Group for Liver Abscess. Risk factor analysis of invasive liver abscess caused by the K1 serotype Klebsiella pneumoniae. Eur J Clin Microbiol Infect Dis 2009;28:109-11.  Back to cited text no. 2
    
3.Jepsen P, Vilstrup H, Schønheyder HC, Sørensen HT. A nationwide study of the incidence and 30-day mortality rate of pyogenic liver abscess in Denmark, 1977-2002. Aliment Pharmacol Ther 2005;21:1185-8.  Back to cited text no. 3
    
4.Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: Ten years experience in a UK centre. QJM 2002;95:797-802.  Back to cited text no. 4
    
5.Yang YS, Siu LK, Yeh KM, Fung CP, Huang SJ, Hung HC, et al. Recurrent Klebsiella pneumoniae liver abscess: Clinical and microbiological characteristics. J Clin Microbiol 2009;47:3336-9.  Back to cited text no. 5
    
6.Hsu WH, Yu FJ, Chuang CH, Chen CF, Lee CT, Lu CY. Occult colon cancer in a patient with diabetes and recurrent Klebsiella pneumoniae liver abscess. Kaohsiung J Med Sci 2009;25:98-103.  Back to cited text no. 6
    
7.Clarençon F, Scatton O, Bruguière E, Silvera S, Afanou G, Soubrane O, et al. Recurrent liver abscess secondary to ingested fish bone migration: Report of a case. Surg Today 2008;38:572-5.  Back to cited text no. 7
    
8.Tsai FC, Huang YT, Chang LY, Wang JT. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis 2008;14:1592-600.  Back to cited text no. 8
    
9.Keynan Y, Rubinstein E. Diabetes mellitus and pyogenic liver abscess: Risk and prognosis. Clin Infect Dis 2007;45:801.  Back to cited text no. 9
[PUBMED]    
10.Yang CC, Yen CH, Ho MW, Wang JH. Comparison of pyogenic liver abscess caused by non-Klebsiella pneumoniae and Klebsiella pneumoniae. J Microbiol Immunol Infect 2004;37:176-84.  Back to cited text no. 10
    
11.Tsai SS, Huang JC, Chen ST, Sun JH, Wang CC, Lin SF, et al. Characteristics of Klebsiella pneumoniae bacteremia in community-acquired and nosocomial infections in diabetic patients. Chang Gung Med J 2010;33:532-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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Abstract
Introduction
Case Report
Discussion
Conclusion
Acknowledgments
Disclosure
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