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An Increasing Prominent Disease of Klebsiella pneumoniae Liver Abscess: Etiology, Diagnosis, and Treatment  [PDF]
Yun Liu,Ji-yao Wang,Wei Jiang
Gastroenterology Research and Practice , 2013, DOI: 10.1155/2013/258514
Abstract: Background. During the past two decades, Klebsiella pneumoniae (K. pneumoniae) had surpassed Escherichia coli (E. coli) as the predominant isolate from patients with pyogenic liver abscess (PLA) in Asian countries, the United States, and Europe, and it tended to spread globally. Since the clinical symptom is atypical, the accurate and effective diagnosis and treatment of K. pneumoniae liver abscesses (KLAs) are very necessary. Methods. Here, we have comprehensively clarified the epidemiology and pathogenesis of KLA, put emphases on the clinical presentations especially the characteristic radiographic findings of KLA, and thoroughly elucidated the most effective antibiotic strategy of KLA. Results. K1 serotype is strongly associated with KLA especially in diabetic patients. Computed tomography (CT) and ultrasound (US) were two main diagnostic methods of KLA in the past. Most of KLAs have solitary, septal lobular abscesses in the right lobe of liver, and they are mainly monomicrobial. Broad-spectrum antibiotics combined with the US-guided percutaneous drainage of liver abscesses can increase their survival rates, but surgical intervention still has its irreplaceable position. Conclusion. The imaging features contribute to the early diagnosis, and the percutaneous intervention combined with an aminoglycoside plus either an extended-spectrum betalactam or a second- or third-generation cephalosporin is a timely and effective treatment of KLA. 1. Introduction Pyogenic liver abscess (PLA) is a life-threatening infectious disease. Before the 1980s, E. coli was the most common pathogen that caused PLA and was mostly polymicrobial. However, during the past two decades, highly virulent strains of K. pneumoniae had emerged as a predominant cause of PLA in Asian countries and areas [1–5], the United States [6–11], and Europe [12–14], especially Taiwan [2, 15–22], and it tended to spread globally [23–26]. Recent researches have shown, unlike other bacterial-induced PLAs (Non-KLAs) which are mostly associated with biliary tract disorders [19, 27–30], that K. pneumoniae liver abscesses (KLAs) are often cryptogenic [3, 6, 17, 27, 29–34]. Metastatic meningitis or endophthalmitis is often complicated with KLA 10%–45% [9, 16, 30, 35–38], and most of KLA patients had diabetes mellitus [1, 15, 16, 22, 27, 29, 30, 35, 38, 39]. KLA has the characteristic radiographic findings which are different from those of Non-KLA [1, 6, 22, 30, 34, 38, 40, 41]. Up to date, the combination of systemic antibiotics and percutaneous drainage has become the treatment of choice for the
Klebsiella pneumoniae Renal Abscess Syndrome: A Rare Case with Metastatic Involvement of Lungs, Eye, and Brain  [PDF]
Divyanshu Dubey,Fayez S. Raza,Anshudha Sawhney,Ambarish Pandey
Case Reports in Infectious Diseases , 2013, DOI: 10.1155/2013/685346
Abstract: We describe a rare case of Klebsiella pneumoniae renal abscess with metastatic spread leading to endopthalmitis, pulmonary cavitary lesions, and cerebral emboli in a 41-year-old Hispanic female with diabetes mellitus who presented with a four-to-five-day history of fevers, headache, eye pain, and vomiting. She was treated with IV antibiotics and made a gradual but full recovery. 1. Introduction Klebsiella pneumoniae, a member of the Enterobacteriaceae family, is a virulent Gram negative organism that causes nosocomial infections. It has a higher tendency to infect immunocompromised patients including those with diabetes. Commonly attributed infections to Klebsiella pneumoniae include urinary tract infections (UTIs) and pneumonias. Rarely, incidence of abscess formation secondary to Klebsiella pneumonia infection has been reported in organ like liver, lung, and brain [1]. In addition, certain serotypes of Klebsiella pneumoniae, particularly K1 and K2, have been reported to involve secondary areas of the body through metastatic spread from the primary abscess [1–8]. Klebsiella liver abscess presenting as a widely metastatic invasive syndrome has been reported in South East Asia [1, 2]. However, only a few cases of renal abscess with metastatic spread have been reported [2–8]. In this report, we describe a rare case of Klebsiella pneumoniae renal abscess with metastatic lesions to the brain, eyes, and lungs. 2. Case Report A 41-year-old Hispanic female with a history of type 2 diabetes mellitus presented with four-to-five days of progressively worsening fever, headache, right eye pain, blurred vision, nausea, and vomiting. She also complained of shortness of breath and pleuritic chest pain over the last twenty four hours. On examination, a hypopyon was visualized in the anterior chamber of right eye, and bilateral crackles were heard on lung auscultation. No significant weakness or numbness was found on neurological exam. Complete blood count showed leukocytosis with neutrophilic predominance. Urine analysis was consistent with urinary tract infection. Her condition deteriorated at this point, and she became confused and disoriented. Cultures were obtained, and she was started on empiric intravenous antibiotics (Vancomycin and Zosyn). Ophthalmology service was consulted, and she was treated with intravitreal injection of vancomycin and ceftazidime. MRIs of her brain and orbits were obtained which showed inflammatory changes surrounding the right ocular globe, consistent with endopthalmitis (Figure 1(a)). There were also multifocal regions of increased
A k2A-positive Klebsiella pneumoniae causes liver and brain abscess in a Saint Kitt's man
Melissa S. Doud, Reni Grimes-Zeppegno, Enrique Molina, Nancimae Miller, Danajeyan Balachandar, Lisa Schneper, Robert Poppiti, Kalai Mathee
International Journal of Medical Sciences , 2009,
Abstract: Klebsiella pneumoniae isolated in community-acquired pneumonia is increasingly found in primary pyogenic liver abscesses. The presence of magA in K. pneumoniae has been implicated in hypermucoviscosity and virulence of liver abscess isolates. The K2 serotype has also been strongly associated with hypervirulence. We report the isolation of non-magA, K2 K. pneumoniae strain from a liver abscess of a Saint Kitt's man who survived the invasive syndrome.
A case report of complicated giant liver abscess caused by ESBL producing Klebsiella pneumoniae  [PDF]
Kadriye Ya?ar,Filiz Pehlivano?lu,Semra Sand?kc?,G?nül ?eng?z
Medical Journal of Bakirk?y , 2012,
Abstract: Liver abscess most frequently occurs secondary to biliary gland and biliary tract diseases with a clinical picture with fever, nausea and vomiting, and right upper abdominal pain. Diabetes mellitus and immunosuppression are risk factors for abscess formation and other complications. Besides technological innovations, radiological technics and invasive procedures have been developed for diagnosis and this has led to decrease in the mortality and morbidity of liver abscess. Abdominal ultrasonography is a frequently used method but, computed tomography is the gold standard for diagnosis. In this study, a 67-year-old diabetic male patient who developed complicated liver abscess after laparoscopic cholesystectomy caused by extended spectrum beta lactamase (ESBL) producing Klebsiella pneumoniae was presented.
Isolation of Genes Involved in Biofilm Formation of a Klebsiella pneumoniae Strain Causing Pyogenic Liver Abscess  [PDF]
Meng-Chuan Wu, Tzu-Lung Lin, Pei-Fang Hsieh, Hui-Ching Yang, Jin-Town Wang
PLOS ONE , 2011, DOI: 10.1371/journal.pone.0023500
Abstract: Background Community-acquired pyogenic liver abscess (PLA) complicated with meningitis and endophthalmitis caused by Klebsiella pneumoniae is an emerging infectious disease. To investigate the mechanisms and effects of biofilm formation of K. pneumoniae causing PLA, microtiter plate assays were used to determine the levels of biofilm formed by K. pneumoniae clinical isolates and to screen for biofilm-altered mutants from a transposon mutant library of a K. pneumoniae PLA-associated strain. Methodology/Principal Findings The biofilm formation of K. pneumoniae was examined by microtiter plate assay. Higher levels of biofilm formation were demonstrated by K. pneumoniae strains associated with PLA. A total of 23 biofilm-decreased mutants and 4 biofilm-increased mutants were identified. Among these mutants, a biofilm-decreased treC mutant displayed less mucoviscosity and produced less capsular polysaccharide (CPS), whereas a biofilm-increased sugE mutant displayed higher mucoviscosity and produced more CPS. The biofilm phenotypes of treC and sugE mutants also were confirmed by glass slide culture. Deletion of treC, which encodes trehalose-6-phosphate hydrolase, impaired bacterial trehalose utilization. Addition of glucose to the culture medium restored the capsule production and biofilm formation in the treC mutant. Transcriptional profile analysis suggested that the increase of CPS production in ΔsugE may reflect elevated cps gene expression (upregulated through rmpA) in combination with increased treC expression. In vivo competition assays demonstrated that the treC mutant strain was attenuated in competitiveness during intragastric infection in mice. Conclusions/Significance Genes important for biofilm formation by K. pneumoniae PLA strain were identified using an in vitro assay. Among the identified genes, treC and sugE affect biofilm formation by modulating CPS production. The importance of treC in gastrointestinal tract colonization suggests that biofilm formation contributes to the establishment and persistence of K. pneumoniae infection.
Klebsiella pneumoniae liver abscess in diabetic patients: association of glycemic control with the clinical characteristics  [cached]
Lin Yi-Tsung,Wang Fu-Der,Wu Ping-Feng,Fung Chang-Phone
BMC Infectious Diseases , 2013, DOI: 10.1186/1471-2334-13-56
Abstract: Background Klebsiella pneumoniae liver abscess (KPLA) has been reported with increasing frequency in East Asian countries in the past 3 decades, especially in Taiwan and Korea. Diabetes is a well-known risk factor for KPLA and highly associated with septic metastatic complications from KPLA. We investigated the association of glycemic control in diabetic patients with the clinical characteristics of KPLA in Taiwan. Methods Adult diabetic patients with KPLA were identified retrospectively in a medical center from January 2007 to January 2012. Clinical characteristics were compared among patients with different levels of current hemoglobin A1c (HbA1c). Risk factors for metastatic infection from KPLA were analyzed. Results Patients with uncontrolled glycemia (HbA1c ≥ 7%) were significantly younger than those with controlled glycemia (HbA1c < 7%). Patients with uncontrolled glycemia had the trend to have a higher rate of gas-forming liver abscess, cryptogenic liver abscess, and metastatic infection than those with controlled glycemia. Cryptogenic liver abscess and metastatic infection were more common in the poor glycemic control group (HbA1c value >; 10%) after adjustment with age. HbA1c level and abscess < 5 cm were independent risk factors for metastatic complications from KPLA. Conclusions Glycemic control in diabetic patients played an essential role in the clinical characteristics of KPLA, especially in metastatic complications from KPLA.
Lipopolysaccharide O1 Antigen Contributes to the Virulence in Klebsiella pneumoniae Causing Pyogenic Liver Abscess  [PDF]
Pei-Fang Hsieh, Tzu-Lung Lin, Feng-Ling Yang, Meng-Chuan Wu, Yi-Jiun Pan, Shih-Hsiung Wu, Jin-Town Wang
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0033155
Abstract: Klebsiella pneumoniae is the common cause of a global emerging infectious disease, community-acquired pyogenic liver abscess (PLA). Capsular polysaccharide (CPS) and lipopolysaccharide (LPS) are critical for this microorganism's ability to spread through the blood and to cause sepsis. While CPS type K1 is an important virulence factor in K. pneumoniae causing PLA, the role of LPS in PLA is not clear. Here, we characterize the role of LPS O antigen in the pathogenesis of K. pneumoniae causing PLA. NTUH-K2044 is a LPS O1 clinical strain; the presence of the O antigen was shown via the presence of 1,3-galactan in the LPS, and of sequences that align with the wb gene cluster, known to produce O-antigen. Serologic analysis of K. pneumoniae clinical isolates demonstrated that the O1 serotype was more prevalent in PLA strains than that in non-tissue-invasive strains (38/42 vs. 9/32, P<0.0001). O1 serotype isolates had a higher frequency of serum resistance, and mutation of the O1 antigen changed serum resistance in K. pneumoniae. A PLA-causing strain of CPS capsular type K2 and LPS serotype O1 (i.e., O1:K2 PLA strain) deleted for the O1 synthesizing genes was profoundly attenuated in virulence, as demonstrated in separate mouse models of septicemia and liver abscess. Immunization of mice with the K2044 magA-mutant (K1? O1) against LPS O1 provided protection against infection with an O1:K2 PLA strain, but not against infection with an O1:K1 PLA strain. Our findings indicate that the O1 antigen of PLA-associated K. pneumoniae contributes to virulence by conveying resistance to serum killing, promoting bacterial dissemination to and colonization of internal organs after the onset of bacteremia, and could be a useful vaccine candidate against infection by an O1:K2 PLA strain.
Pyogenic Liver Abscess, Bacteremia, and Meningitis with Hypermucoviscous Klebsiella pneumoniae: An Unusual Case Report in a Human T-Cell Lymphotropic Virus Positive Patient of Caribbean Origin in the United States  [PDF]
Gargi Patel,Neha Shah,Roopali Sharma
Case Reports in Infectious Diseases , 2013, DOI: 10.1155/2013/676340
Abstract: Pyogenic liver abscess (PLA) is a potentially fatal disease. Klebsiella pneumoniae (K. pneumoniae) has replaced Escherichia coli (E. coli) as the predominant causative organism for pyogenic liver abscess. Over the years a unique form of community-acquired invasive K. pneumoniae infection of the liver has been well described in Southeast Asia. This has recently been linked to a virulent hypermucoviscous K. pneumoniae phenotype and to a specific genotype, rmpA positive. To our knowledge, we report the first case of PLA with bacteremia and meningitis in a Guyanese patient with the presence of rmpA-positive K. pneumoniae with laboratory evidence in North America. 1. Introduction For the past few decades, an increased incidence of distinct community-acquired invasive K. pneumoniae syndrome in Taiwan and other Southeast Asian countries has been characterized by bacteremia, liver abscesses, and metastatic infections of the CNS, eye, and other sites [1, 2]. This invasive K. pneumoniae syndrome has also been reported as an emerging infection in the United States and other countries [3, 4]. Patients with this syndrome have been reported to be immunocompetent and with no underlying gastrointestinal pathology. Although diabetes mellitus seems to be an important risk factor in patients who acquire this infection, the mortality rate has been reported to be 2.8%–10.8% [5]. The invasiveness of K. pneumoniae is related to the hypermucoviscosity phenotype of the strain expressed by mucoviscosity-associated gene A (magA) and regulator of mucoid phenotype A (rmpA) [6, 7] The rmpA gene is a plasmid-mediated regulator of the extracapsular polysaccharide synthesis which is associated with hypermucoviscosity phenotype as well as with the K. pneumoniae invasive clinical syndrome [7]. We describe a case of pyogenic liver abscess, bacteremia, and meningitis with a hypermucoviscous K. pneumonia rmpA positive strain in a patient who was Human T-cell lymphotropic virus (HTLV-1) positive. 2. Case Report A 68-year-old Guyanese woman with a history of cervical cancer (treated 20 years ago), Alzheimer’s dementia, and depression presented to our institution in November 2011 with approximately a 2-day history of left shoulder pain radiating to the entire left side, headache, one episode of diarrhea, chronic abdominal pain, dizziness, blurriness, nuchal rigidity, photophobia, loss of appetite, and altered mental status. At admission, she was febrile (100.8°F) and tachycardic (99 beats per minute). The patient denied any sick contacts and had last traveled to Guyana two years ago. Of note,
A Case of Carbapenem Resistant Non-K1/K2 Serotype Klebsiella pneumoniae Liver Abscess  [PDF]
Lucy Cheng, Leung Kristopher Siu, Tom Chiang
Advances in Infectious Diseases (AID) , 2013, DOI: 10.4236/aid.2013.33032
Abstract:

Klebsiella pneumoniae liver abscess (KPLA) has been described as an invasive syndrome with extrahepatic complications. The majority of KPLA is caused by capsular serotype K1 and K2 isolates. We report a case of carbapenem resistant Klebsiella pneumoniae liver abscess. The patient initially presented with infected right above-the-knee amputation and was later found with a large liver abscess. Initial antimicrobial susceptibility showed carbapenem resistant K. pneumoniae (CRKP). Further molecular workup revealed that the isolate was a less virulent non-K1/K2 serotype, and both rmpA and kfu genes were negative. The lack of outer membrane porins likely contributed to the carbapenem resistance. To our knowledge, this is a first reported case of carbapenem resistant, non-K1/K2 serotype K. pneumoniae liver abscess in the United States.

Differences in characteristics between healthcare-associated and community-acquired infection in community-onset Klebsiella pneumoniae bloodstream infection in Korea  [cached]
Jung Younghee,Lee Myung,Sin Hye-Yun,Kim Nak-Hyun
BMC Infectious Diseases , 2012, DOI: 10.1186/1471-2334-12-239
Abstract: Background Healthcare-associated (HCA) infection has emerged as a new epidemiological category. The aim of this study was to evaluate the impact of HCA infection on mortality in community-onset Klebsiella pneumoniae bloodstream infection (KpBSI). Methods We conducted a retrospective study in two tertiary-care hospitals over a 6-year period. All adult patients with KpBSI within 48 hours of admission were enrolled. We compared the clinical characteristics of HCA and community-acquired (CA) infection, and analyzed risk factors for mortality in patients with community-onset KpBSI. Results Of 553 patients with community-onset KpBSI, 313 (57%) were classified as HCA- KpBSI and 240 (43%) as CA-KpBSI. In patients with HCA-KpBSI, the severity of the underlying diseases was higher than in patients with CA-KpBSI. Overall the most common site of infection was the pancreatobiliary tract. Liver abscess was more common in CA-KpBSI, whereas peritonitis and primary bacteremia were more common in HCA-KpBSI. Isolates not susceptible to extended-spectrum cephalosporin were more common in HCA- KpBSI than in CA-KpBSI (9% [29/313] vs. 3% [8/240]; p = 0.006). Overall 30-day mortality rate was significantly higher in HCA-KpBSI than in CA-KpBSI (22% [70/313] vs. 11% [27/240]; p = 0.001). In multivariate analysis, high Charlson’s weighted index of co-morbidity, high Pitt bacteremia score, neutropenia, polymicrobial infection and inappropriate empirical antimicrobial therapy were significant risk factors for 30-day mortality. Conclusions HCA-KpBSI in community-onset KpBSI has distinctive characteristics and has a poorer prognosis than CA-KpBSI, but HCA infection was not an independent risk factor for 30-day mortality.
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