March 1, 2008

EIN Reports Cases of Hyperviscous Klebsiella pneumoniae with Liver Abscesses

Note: The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of the EIN, the Infectious Diseases Society of America (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using information posted on this electronic mail conference.

An EIN member in Oregon wrote: “We just discharged a 42-year-old Filipino male after 21 days of hospitalization and 10 drainage procedures for multiple liver abscesses due to a hyperviscous strain of Klebsiella pneumoniae. The illness is consistent with that described in several reports from Southeast Asia and one from North America (Clin Infect Dis. 2007;45:e25-28). The organism had a positive "string test" (figure 1) [described in the CID reference].

Figure 1. Laboratory test results for Klebsiella pneumoniae. A, Results of the string test.

“Has anyone encountered such patients—especially in patients of Asian descent or Hispanics? Our patient responded slowly, if at all, to various antibiotics, or combinations, of antibiotics. To my knowledge, no one has identified a genetic predisposition. We received one suggestion to look for occult chronic granulomatous disease and appropriate tests are in process.”

Here is a sampling of responses:

California: We have had three cases with in the past two months. Two patients are of Asian descent and one is Hispanic. All three had endogenous endophthalmitis and liver abscesses. They seem to have a similar resistance pattern (resistant to ampicillin only). I have not found any genetic predisposition noted in the literature.

Pennsylvania: This invasive syndrome of bacteremic Klebsiella pneumoniae with liver abscess and, occasionally, endophthalmitis is now in the United States! While it is appropriate to search for chronic granulomatous disease, these patients typically have no underlying diseases except for diabetes mellitus, which may become manifest during the infection. The patients are usually Asians who are recent arrivals. We have now seen two cases in non-Asians who have not been to Asia.

The typical presentation in the United States is the finding of K. pneumoniae bacteremia in a patient with liver abscess. The U.S. cases have generally responded poorly because intravenous antibiotics are accepted as the first line of therapy for liver abscess. The Taiwanese ID specialists have learned that expeditious drainage of the abscesses is advantageous.

The key clue will come from the clinical microbiology lab. The Klebsiella has a strikingly large sticky mucoid capsule. A color photo demonstrating the "string test" can be seen on p. 987 of Emerging Infectious Diseases 2007;13:986-993.

Singapore: Screen for undiagnosed diabetes, and look for abscesses in other locations.

I had one chap three years ago, a 46-year-old, previously healthy computer programmer, drinking lots of Coke to meet project deadlines, present with high fevers, leukocytosis, a right arm abscess (13 cm), and two leg abscesses. These were drained by the orthopedists. Blood cultures were positive for Klebsiella, but fevers persisted despite appropriate antibiotics.

Further scanning showed liver and prostatic abscesses, and the stubborn fevers resolved after all collections of pus were found and drained. His HbA1c was 15, and he had five or six separate abscess locations.

Connecticut: I had seen one patient in early 2007 with a similar problem. He was of Asian descent and had a liver abscess—a presumed 'hyperviscous' strain of Klebsiella pneumoniae was obtained from the abscess. The string test was positive. I treated him with ertapenem because we were concerned about other gut flora involved.

In my reading at that time, this phenomenon had been noted in people of Asian descent but the predisposition has not been studied. We did not look for other occult processes. He responded very well to therapy with improvement in the abscesses. I cannot comment about complete resolution because he moved to another city and changed providers.

California (2): I recently had a 50-year-old Caucasian female with extensive colon cancer stage 4 with multiple metastases to her liver who developed biliary obstruction; a stent was placed by interventional radiology. She had Klebsiella (resistant to ampicillin) sepsis, and multiple abscesses after the stent was obstructed due to metastases; it was drained but she still had several abscesses. Due to extensive metastases, no further drainage was done. She died a week ago from sepsis and extensive cancer.

Oregon (original poster): Looks like we have a problem. When you look under the rock…

EIN is interested in any additional reports of cases of this pathogen. Please e-mail with any information.

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