|Year : 2014 | Volume
| Issue : 2 | Page : 104-107
Community-acquired primary liver abscess due to klebsiella pneumoniae in a type 2 diabetic patient
Fatima Bello, Yakub Lawal, Adamu Girei Bakari
Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Submission||12-Nov-2013|
|Date of Acceptance||10-Feb-2014|
|Date of Web Publication||16-Jul-2014|
Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: The writing of this case report was personally funded, Conflict of Interest: There is no confl ict of interest in the writing of this case report
Klebsiella pneumonia (KPLA) liver abscess is a cause of morbidity and mortality in especially diabetic patients. Early case reports have been from the Southeast Asia, also been found in other parts of the world. Diagnosis is usually by culture of hepatic aspirate and/or blood culture and treatment by drainage of abscess and administration of appropriate antibiotics. This is a case of KPLA in a 52-year old man treated and responded to antibiotics. KPLA is an entity that should be sought for especially in poorly controlled diabetic patients when they present with clinical features of liver abscess. Blood culture must always be done especially when aspiration or drainage proves difficult. Use of appropriate antibiotics alone may be successful in treating them if surgical drainage is unsuccessful.
Keywords: Blood culture, gentamicin, klebsiella pneumoniae, type 2 diabetes
|How to cite this article:|
Bello F, Lawal Y, Bakari AG. Community-acquired primary liver abscess due to klebsiella pneumoniae in a type 2 diabetic patient. Sub-Saharan Afr J Med 2014;1:104-7
|How to cite this URL:|
Bello F, Lawal Y, Bakari AG. Community-acquired primary liver abscess due to klebsiella pneumoniae in a type 2 diabetic patient. Sub-Saharan Afr J Med [serial online] 2014 [cited 2019 Oct 20];1:104-7. Available from: http://www.ssajm.org/text.asp?2014/1/2/104/136824
| Introduction|| |
0Klebsiella pneumoniae liver abscess (KPLA) is a cause of morbidity and mortality worldwide. , It was first described in Taiwan in 1986 and currently accounts for 78.5% of all liver abscesses in Taiwan. ,, It is being reported with increasing frequency in other countries in southeast Asian countries , and has become an emerging infectious disease in the United states and worldwide. ,, It has not been widely reported in Nigeria and Africa as a whole. Victor et al., reported some cases in South Africa where they explained that the geographic differences in clinical manifestations including host factors such as rates of diabetes mellitus, alcoholism, access to healthcare, and socioeconomic factors.  It is often complicated by bacteremia, sepsis, and metastatic infection of the central nervous system, eye, and other sites.  The mortality rate has a range of 2.8%-10.8%. ,
The most important K. pneumoniae virulence factors are heavy encapsulation of K1 and K2 strains; resistance to phagocytosis; the presence of mucoviscosity-associated gene A (magA), a capsule-associated virulence gene; and the presence of regulator of mucoid phenotype A (rmpA), a plasmid-mediated regulator of the extracapsular polysaccharide synthesis. ,
In a study conducted by Yang et al.,  the diagnosis of pyogenic liver abscess was based on ultrasound or CT imaging with any of positive pus and/or blood cultures, or lesions subsidence after antibiotic treatment despite lack of positive cultures or non-performance of invasive procedures. Similar criteria was used by Fung et al., in their study,  however they excluded patients with a positive blood culture who lack liver aspirate culture. Percutaneous aspiration or pigtail drainage of the liver abscess in combination with antibiotics especially cephalosporin has become the main therapeutic modality. ,,, Differential diagnosis include amoebic abscess, tumors, biliary pathologies and hemangioma. 
The dearth of the literature on Klebsiella pneumoniae liver abscess has necessitated that this case be reported to keep physicians at alert and have a high index of suspicion in order to diagnose this condition early supported by such investigations as ultrasound, CT scan and culture of liver aspirates or blood. As to whether KPLA is rare or simply underreported in Nigeria and Africa as a whole remains to be investigated.
| Case report|| |
A 52 year-old male pharmacy technician was admitted with a week history of fever, right hypochondrial pain, vomiting and polyuria. Fever was high grade, intermittent and associated with chills and rigors.
M.A has had recurrent visual blurring over the previous 3 years and also suffered erectile dysfunction for 4 years prior to present admission. He is a known type 2 diabetic of 11 years duration placed on metformin 500 mg every 12 h and glibenclamide 5 mg once daily but not regular on them. The last visit to the hospital was over 4 months. He is not a known hypertensive. M.A is married to a wife with 8 children and neither smokes cigarette nor ingests alcohol.
On general physical examination, he was conscious but lethargic, febrile (axillary temperature 39.8○ C), icteric, not pale, no significant peripheral lymphadenopathy, no pitting pedal edema.
Abdominal examination revealed a tender hepatomegaly of 4 cm below right costal margin, firm, smooth surfaced with a span of 14 cm. The spleen was not palpably enlarged and the kidneys were not bimanually palpable. No ascites was demonstrated.
A pulse rate of 104 bpm was recorded, blood pressure 120/70 mmHg right arm supine and the jugular venous pressure not elevated. Heart sounds were normal S1 and S2 and the chest was clinically clear. Ophthalmic examination by the ophthalmologist revealed no abnormality of the anterior segment and no features suggestive of endophthalmitis. The fundus however revealed hard exudates and dot hemorrhages (non-proliferative diabetic retinopathy) otherwise, the central nervous system examination was grossly normal.
Investigation results with local normal ranges in brackets include complete blood count which showed a packed cell volume (%) of 45 (36-54), white blood cell count (10 9 /L) 13.7 (2.0-9.0) with differential count (%) revealing absolute neutrophilia 78 (40-60) with toxic granulation and left shift, lymphocyte 20 (20-40), eosinophil 2 (1-6) and platelet count (10 9 /L) 310 (150-450). Serum urea/electrolytes (mmol/L) include urea 3.7 (2.5-6.5), sodium 140 (136-145), potassium 3.6 (3.6-5.2), chloride 100 (94-108), bicarbonate 24 (24-32) and creatinine (microMol/L) 90 (9-126). Liver function tests (LFTs) show aspartate transaminase (IU/L) 25 (5-22), alanine transaminase (IU/L) 44 (16-40),alkaline phosphatase (IU/L) 94 (21-92), total bilirubin (microMol/L) 28 (4-17) with conjugated bilirubin 24 microMol/L. Clotting profile in seconds (s) includes prothrombin time 17s (control 15s) and activated partial thromboplastin time 31s (control 38s).
[Figure 1] is the abdominal ultrasound of the patient which shows an irregular mixed echogenic lesion (5.2 × 4.6 cm 2 ) within the right lobe with multiple echogenic foci noted around it suggestive of hepatic abscess. There is no biliary dilatation seen. The gall bladder, spleen, pancreas, bowel loops, para-aortic areas, kidneys and the urinary bladder are within normal limits.
Klebsiella pneumoniae sensitive to gentamicin was isolated from the two consecutive blood cultures taken at interval of 12 h from different sites. There was resistance to ceftriaxone, augmentin, cefuroxime, septrin and erythromycin. The brain-heart infusion (biphasic) culture medium was used with a subculture on the McConkey agar. Positive cultures were obtained in less than 12 h from both blood samples, two bottles each and stickiness on agar plate was demonstrated using wire loop (the string test) indicating hypermucoviscosity (virulent) phenotype. Serotyping for K1 or K2 was not done for logistic reasons. Susceptibility to antimicrobial agents was determined by using the Bauer-Kirby disk-diffusion method on Mueller-Hinton agar medium manufactured by Oxoid ltd Basingstoke, England. The interpretation was performed according to the clinical laboratory standards institute (CSLI) guidelines; sensitive (>15 mm), intermediate resistance (13-14 mm) and resistant (<12 mm) for enterobacteriaceae.  There was no organism isolated from both urine and stool culture using the McConkey agar.
Blood glucose levels (mmol/L) with local ranges for acceptable control of diabetes in bracket include admitting random blood glucose 21.3 (4.0-10.0). Subsequently fasting and 2-hour post-prandial blood glucose levels were 18.1 (4.0-8.0) and 21.9 (4.0-10.0), respectively. Glycated hemoglobin (%) was 12.7 (4.0-7.0) indicating poor glycaemic control over at least the previous 2 months.
M.A was treated with intravenous normal saline, soluble insulin and empiric antibiotics (ceftriaxone, metronidazole). Attempt at ultrasound-guided aspiration/drainage of the hepatic abscess failed. Fever continued with a swinging pattern until the 7 th day of admission when intravenous gentamicin was added to the antibiotic regimen based on the blood culture sensitivity. Though ceftriaxone resistance was shown on both culture results, it was continued due to the literature evidence of its efficacy in KPLA. A downward trend was then, noticed on the temperature chart until a week later when the patient became afebrile and abdominal pain subsided. Repeat ultrasound [Figure 2] and blood culture showed a resolution of the abscess and negative blood culture, respectively, and was subsequently discharged. Follow up 3 months later showed patient doing well.
| Discussion|| |
The diagnosis of Klebsiella pneumoniae liver abscess in this patient was made on the basis of ultrasonographic finding and blood culture result and such clinical features as swinging fever, right hypochondrial pain, vomiting and tender hepatomegaly. This was further strengthened by the resolution of symptoms, signs, ultrasonographic evidence of liver abscess and negative repeat blood culture following addition of gentamicin to antibiotic regimen based on blood culture sensitivity result. Similar criteria for diagnosis were used by Yang et al. as mentioned above though Fung et al., excluded patients with positive blood culture but no tissue culture.
The liver abscess is said to be community acquired because though, the patient is a pharmacy technician, he practices in a private pharmacy outlet as at presentation and stays within the community most of the time. In addition, his last visit to the hospital was over 4 months.
The patient's chronic diabetic status for 11 years and poor glycaemic control (HbA1c 12.7%) are factors that predisposed him to pyogenic liver abscess. Several aspects of immunity are altered in patients with diabetes. Polymorphonuclear leukocyte and macrophage (including kupffer cells) functions are depressed particularly in this patient with poor glycaemic control. Leukocyte adherence, chemotaxis, phagocytosis and antioxidant bactericidal activity are impaired in the systemic circulation and locally in the liver. Total white blood cell count of 13.7 × 10 9 /L with absolute neutrophilia (78%), toxic granulations and left shift suggest an acute bacterial infection. The lesions in our patient were located in the right lobe similar to findings in most of the patients in the study by Yang et al. The ultrasonographic finding of an irregular mixed echogenic lesion (5.2 × 4.6 cm 2 ) within the right lobe with multiple echogenic foci noted around it is highly suggestive of pyogenic liver abscess than amoebic abscess, tumor or haemangioma. The absence of biliary dilatation seen also makes biliary pathologies unlikely. The absence of isolate from the stool culture makes the gut unlikely to be the source of infection. Attempt at aspiration of the liver abscess in our patient failed and the procedure was abandoned to avoid undue discomfort to the patient. Some authors have also reported such failed attempts especially when the abscesses are small and multiple. ,, Though, percutaneous aspiration or pigtail drainage in combination with antibiotics is the main therapeutic modality for management of pyogenic liver abscesses, our patient did well on antibiotics (gentamicin) alone based on sensitivity result. The initial choice of ceftriaxone as empiric antibiotic was informed by the literature evidence of its efficacy in pyogenic liver abscesses. Previous series reported high mortality rates associated with treatment with antibiotics alone and with multiple abscesses. ,,
| Conclusion|| |
0Klebsiella pneumoniae liver abscess is an entity that should be sought for especially in poorly controlled diabetic patients when they present with clinical features of liver abscess. Blood culture must always be done especially when aspiration or drainage proves difficult. Use of appropriate antibiotics alone can be successful in treating them especially in poor-resource setting and/or when surgical drainage is unsuccessful. Morbidity and mortality can be markedly reduced if culture and sensitivity results of blood or other tissues are obtained early. It remains to be investigated whether this entity is actually rare or simply under-reported in Nigeria and Africa as a whole.
| References|| |
|1.||Tsai FC, Huang YT, Chang LY, Wang JT. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis 2008;14:1592-600. |
|2.||Liu YC, Cheng DL, Lin CL. Klebsiella pneumoniae liver abscess associated with septic endophthalmitis. Arch Intern Med 1986;146:1913-6. |
|3.||Chang FY, Chou MY. Comparison of pyogenic liver abscesses caused by Klebsiella pneumoniae and non-K. pneumoniae pathogens. J Formos Med Assoc 1995;94:232-7. |
|4.||Chung DR, Lee SS, Lee HR. Emerging invasive liver abscess caused by K1 serotype Klebsiella pneumoniae in Korea. J Infect 2007;54:578-83. |
|5.||Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella pneumoniae as a primary pathogen: An emerging disease with unique clinical characteristics. Am J Gastroenterol 2005;100:322-31. |
|6.||Nadasy KA, Domiati-Saad R, Tribble MA. Invasive Klebsiella pneumonia syndrome in North America. Clin Infect Dis 2007;45:25-8. |
|7.||Keynan Y, Karlowsky JA, Walus T, Rubinstein E. Pyogenic liver abscess caused by hypermucoviscous Klebsiella pneumoniae. Scand J Infect Dis 2007;39:828-30. |
|8.||Victor LY, Dennis SH, Wen Chien Ko, Asia S, Keith PK, Anne G, et al. Virulence Characteristics of Klebsiella and Clinical Manifestations of K. pneumoniae Bloodstream Infections. Emerg Infect Dis 2007;13:986-93. |
|9.||Cheng DL, Liu YC, Yen MY, Liu CY, Shi FW, Wang LS. Pyogenic liver abscess: Clinical manifestations and value of percutaneous catheter drainage treatment. J Formos Med Assoc 1990;89:571-6. |
|10.||Wang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, et al. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998;26:1434-8. |
|11.||Lee KT, Wong SR, Sheen PC. Pyogenic liver abscess: An audit of 10 years' experience and analysis of risk factors. Dig Surg 2001;18:459-65. |
|12.||Cheng DL, Liu YC, Yen MY, Liu CY, Wang RS. Septic metastatic lesions of pyogenic liver abscess: Their association with Klebsiella pneumonia bacteremia in diabetic patients. Arch Intern Med 1991;151:1557-9. |
|13.||Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmology 2007;114:876-80. |
|14.||Fung CP, Chang FY, Lee SC, Hu BS, Kuo BI, Liu CY, et al. A global emerging disease of Klebsiella pneumoniae liver abscess: Is serotype K1 an important factor for complicated endophthalmitis? Gut 2002;50:420-4. |
|15.||Seeto RK, Rockey DC. Pyogenic liver abscess: Changes in etiology, management, and outcome. Medicine 1996;75:99-113. |
|16.||Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, et al. Treatment of pyogenic liver abscess: Prospective randomized comparison of catheter drainage and needle aspiration. Hepatology 2004;39:932-8. |
|17.||Erinle SA, Inikori AK. Current views on ultrasonography in the management of pyogenic liver abscess-challenge to practitioners in sub-saharan Africa. Niger J Clin Pract 2007;10:247-51. |
|18.||McDonald MI, Corey GR, Gallis HA, Durack DT. Single and multiple pyogenic liver abscesses: Natural history, diagnosis and treatment, with emphasis on percutaneous drainage. Medicine 1984;63:291-302. |
|19.||Feng LY, Yang LY, Liao PC, Chou JC, Tsai KC, Yang AS, et al. Structure and Immunological Characterization of the the Capsular Polysaccharide of a Pyrogenic Liver Abscess Caused by Klebsiella pneumoniae; activation of macrophages through toll-like receptor 4. J Biol Chem 2011;286:21041-51. |
|20.||Clinical and Laboratory Standards Institute. M2-A9 Performance standards for antimicrobial disk susceptibility tests; approved standard. 9 th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2006. |
[Figure 1], [Figure 2]