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with fluid and internal septae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Simultaneously&#44; the patient was diagnosed with diabetes mellitus and Kp resistant only to ampicillin was isolated in 2 blood cultures&#46; The antibiotic was changed to amoxicillin-clavulanic acid plus metronidazole and the patient became afebrile and without pain&#46; Percutaneous drainage was not executed due to high risk related to subphrenic location&#46; Subsequent contrast CT-scan also revealed multiple nodules on both lungs&#44; mostly peripheral&#44; the bigger ones being cavitated and were considered as septic pulmonary emboli &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patient was discharged after 2 weeks&#44; antibiotics were continued until 8 weeks and no recurrence has been reported after 2 years &#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We believe that this patient had a distinctive form of community acquired <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> &#40;Kp&#41; infection causing liver abscess and complicated with septic metastatic pulmonary emboli&#44; forming abscesses&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Liver abscess due to <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> &#40;KLA&#41; is a distinct syndrome characterized by monomicrobial liver abscess&#44; almost exclusively acquired in the community and in the absence of hepatobiliary disease&#46; It is strongly associated with diabetes mellitus and Asian ethnicity and has a higher probability of complicating with metastatic infection sites than liver abscesses of other etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Some particularly virulent strains expressing hypermucoviscous phenotype are responsible for this invasive syndrome&#44; despite not being naturally resistant to antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It was geographically confined to Southeast Asia until the past decade&#44; when other reported cases indicate the emergence of this syndrome worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In up to 11&#8211;12&#37; of cases&#44; KLA can be complicated with other septic metastatic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient was Caucasian and a 74-year-old male&#44; consistent with published demographic data&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> He fulfilled the requested diagnosis criteria for KLA<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a>&#59; 1&#46; Clinical symptoms and laboratory findings of liver abscess&#58; fever&#44; chills&#44; referred scapular pain&#44; elevation of white-blood cell count and C-reactive protein&#44; abnormal liver function tests&#59; 2&#46; Compatible imaging&#58; as in this case&#44; KLA has distinctive imaging features&#44; being more often single&#44; solid in appearance and septated&#44; comprising multiple non-communicating locules&#59; 3&#46; Isolation of Kp in blood culture&#47;abscess aspiration culture&#58; although serotyping was not conducted&#44; antimicrobial susceptibility of Kp isolated in blood culture meets the characteristic pattern of virulent KLA&#44; described to be resistant to ampicillin and ticarcillin&#47;carbenicillin but susceptible to all other antibiotics&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">That this patient had no underlying hepatobiliary disease&#44; no previous hospitalizations or antibiotic use having acquired Kp in the community&#44; also favored this diagnosis&#46; Furthermore&#44; he was simultaneously diagnosed with diabetes mellitus&#44; the most common host risk factor for KLA&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Metastatic complications are more frequent in KLA than liver abscesses of other etiologies<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; They can occur in up to 11&#8211;12&#37;&#44; most commonly as endoftalmitis and meningites but SPE is a rare complication and it is generally present at hospital admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> Our patient met SPE diagnostic criteria&#58; had dry cough and hypocapnia&#44; lung infiltrates&#44; KLA as the embolic source&#44; other potential explanations for lung infiltrates excluded and lung infiltrates resolved after appropriate antimicrobial therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> A broad spectrum of CT-scan findings can be present but less commonly compatible with lung abscesses&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; we describe a case of KLA with high clinical importance since it is the second case reported in Portugal <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; 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Letter to the Editor
Community-acquired Klebsiella pneumoniae liver abscess: a case complicated by metastatic lung abscesses
Maria Inês Matiasa,
Corresponding author
minesleitao@gmail.com

Corresponding author.
, Daniela Soares Santosb, Maria Teresa Diasb, Patrícia Carvalhob, Arsénio Santosb, Rui M. Santosb
a Centro Hospital e Universitário de Coimbra, Serviço de Pneumologia A, Coimbra, Portugal
b Centro Hospital e Universitário de Coimbra, Serviço de Medicina Interna, Coimbra, Portugal
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with fluid and internal septae &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Simultaneously&#44; the patient was diagnosed with diabetes mellitus and Kp resistant only to ampicillin was isolated in 2 blood cultures&#46; The antibiotic was changed to amoxicillin-clavulanic acid plus metronidazole and the patient became afebrile and without pain&#46; Percutaneous drainage was not executed due to high risk related to subphrenic location&#46; Subsequent contrast CT-scan also revealed multiple nodules on both lungs&#44; mostly peripheral&#44; the bigger ones being cavitated and were considered as septic pulmonary emboli &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patient was discharged after 2 weeks&#44; antibiotics were continued until 8 weeks and no recurrence has been reported after 2 years &#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">We believe that this patient had a distinctive form of community acquired <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> &#40;Kp&#41; infection causing liver abscess and complicated with septic metastatic pulmonary emboli&#44; forming abscesses&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Liver abscess due to <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> &#40;KLA&#41; is a distinct syndrome characterized by monomicrobial liver abscess&#44; almost exclusively acquired in the community and in the absence of hepatobiliary disease&#46; It is strongly associated with diabetes mellitus and Asian ethnicity and has a higher probability of complicating with metastatic infection sites than liver abscesses of other etiologies&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Some particularly virulent strains expressing hypermucoviscous phenotype are responsible for this invasive syndrome&#44; despite not being naturally resistant to antibiotics&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It was geographically confined to Southeast Asia until the past decade&#44; when other reported cases indicate the emergence of this syndrome worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In up to 11&#8211;12&#37; of cases&#44; KLA can be complicated with other septic metastatic lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient was Caucasian and a 74-year-old male&#44; consistent with published demographic data&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> He fulfilled the requested diagnosis criteria for KLA<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a>&#59; 1&#46; Clinical symptoms and laboratory findings of liver abscess&#58; fever&#44; chills&#44; referred scapular pain&#44; elevation of white-blood cell count and C-reactive protein&#44; abnormal liver function tests&#59; 2&#46; Compatible imaging&#58; as in this case&#44; KLA has distinctive imaging features&#44; being more often single&#44; solid in appearance and septated&#44; comprising multiple non-communicating locules&#59; 3&#46; Isolation of Kp in blood culture&#47;abscess aspiration culture&#58; although serotyping was not conducted&#44; antimicrobial susceptibility of Kp isolated in blood culture meets the characteristic pattern of virulent KLA&#44; described to be resistant to ampicillin and ticarcillin&#47;carbenicillin but susceptible to all other antibiotics&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">That this patient had no underlying hepatobiliary disease&#44; no previous hospitalizations or antibiotic use having acquired Kp in the community&#44; also favored this diagnosis&#46; Furthermore&#44; he was simultaneously diagnosed with diabetes mellitus&#44; the most common host risk factor for KLA&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Metastatic complications are more frequent in KLA than liver abscesses of other etiologies<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; They can occur in up to 11&#8211;12&#37;&#44; most commonly as endoftalmitis and meningites but SPE is a rare complication and it is generally present at hospital admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> Our patient met SPE diagnostic criteria&#58; had dry cough and hypocapnia&#44; lung infiltrates&#44; KLA as the embolic source&#44; other potential explanations for lung infiltrates excluded and lung infiltrates resolved after appropriate antimicrobial therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> A broad spectrum of CT-scan findings can be present but less commonly compatible with lung abscesses&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; we describe a case of KLA with high clinical importance since it is the second case reported in Portugal <a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; and the only one with the exceptionally rare complication of lung abscesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;7</span></a> This case is an additional proof of the emergence of this syndrome worldwide&#46; In cases of multiple lung abscesses with an acute presentation with dry cough in diabetic patients Kp should be considered&#44; since it may be the first manifestation of serious underlying infection&#46;</p></span>"
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