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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 23  |  Issue : 2  |  Page : 85-87

Pyogenic liver abscess due to multidrug-resistant Klebsiella pneumoniae


Department of Microbiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission04-Oct-2021
Date of Decision29-Oct-2021
Date of Acceptance01-Nov-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Dr. Udhayasankar Ranganathan
Department of Microbiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry - 605 107
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacm.jacm_63_21

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  Abstract 


Pyogenic liver abscess (PLA) is a space-occupying lesion in the liver associated with high morbidity and mortality. There are many risk factors associated with PLA such as underlying hepatobiliary disease, gastrointestinal malignancy, diabetes mellitus and alcoholism. Most PLA cases are polymicrobial caused by mixed enteric facultative and obligate anaerobic bacteria. Here, we present a case of multiple liver abscess caused by Klebsiella pneumoniae in a 46-year-old elderly patient who presented with gastrointestinal symptoms.

Keywords: Klebsiella pneumoniae, multidrug resistance, pyogenic liver abscess


How to cite this article:
Subramanian N, Ranganathan U, Rangasamy G, Thiyagarajan M, Shivekar SS. Pyogenic liver abscess due to multidrug-resistant Klebsiella pneumoniae. J Acad Clin Microbiol 2021;23:85-7

How to cite this URL:
Subramanian N, Ranganathan U, Rangasamy G, Thiyagarajan M, Shivekar SS. Pyogenic liver abscess due to multidrug-resistant Klebsiella pneumoniae. J Acad Clin Microbiol [serial online] 2021 [cited 2022 Jul 1];23:85-7. Available from: https://www.jacmjournal.org/text.asp?2021/23/2/85/336588




  Introduction Top


Bacterial abscess of the liver is a potentially life-threatening condition described since the ages of Hippocrates.[1] The three major forms of liver abscess are amoebic abscess, pyogenic abscess and a relatively rare fungal abscess. While amoebic liver abscess is common in endemic areas of amoebiasis, pyogenic liver abscess (PLA) is common in developed countries. The incidence of liver abscess shows a wide range of variation. As estimated by the World Health Organization in 1995, approximately 40–50 million people worldwide are symptomatic with amoebic colitis or liver abscess, resulting in 40,000–100,000 deaths each year. The incidence of PLA ranges from 8 to 20 cases per million people.[2] PLA, in the antibiotic era, carries a good prognosis with the advent of newer imaging techniques and availability of newer antimicrobial agents. We present here a case of PLA in a 46-year-old male with no underlying risk factor who responded to medical management.


  Case Report Top


A 46-year-old male, farmer by occupation, presented with complaints of abdominal distension for 10 days, abdominal pain, vomiting and loose stools for four days. The patient is a known alcoholic for 20 years. On examination, the patient was conscious, oriented, afebrile with normal vitals. Respiratory system, cardiovascular system and central nervous system were clinically normal. Abdominal examination showed a firm mass in the epigastrium, moving with respiration. It was non-tender, but the patient felt discomfort on deep palpation. Routine laboratory investigations showed neutrophilic leucocytosis, elevated erythrocyte sedimentation rate (ESR), normal liver function and normal serum electrolytes. An ultrasound of the abdomen and pelvis showed multiple hepatic cysts. Contrast Enhanced Computerized Tomography (CECT) scan of the abdomen showed mild hepatomegaly and multiple well defined fluid filled lesions in both lobes of the liver. The approximate volume of the lesions were 25 cubic centimeter. Few of the lesions showed internal septations [Figure 1]. Ultrasound-guided aspirate from the liver abscess was received in the microbiology laboratory. Gram stain of the sample showed plenty of pus cells and few Gram-negative bacilli with capsule. Ziehl–Neelsen staining did not reveal any acid-fast organisms. Aerobic bacterial culture of the pus sample yielded pure growth of Klebsiella pneumoniae after 24 h of enrichment with brain–heart infusion broth which was identified by conventional phenotypic methods. Antimicrobial susceptibility testing (AST) was done by Kirby–Bauer disc diffusion method, and the organism was found to be resistant to most of the commonly used antibiotics such as Ampicillin, Ceftriaxone, Cefotaxime, Ceftazidime, Piperacillin-Tazobactam, Ciprofloxacin, Gentamicin and Tobramycin. It was found to be susceptible to the Carbapenems, Meropenem and Imipenem. Blood culture from the patient did not show any growth after seven days of aerobic incubation. The patient was empirically started on intravenous Ceftriaxone and Metronidazole which was later switched to intravenous Meropenem following the AST report. The patient recovered symptomatically and was discharged upon request, with an advice to follow-up after one week.
Figure 1: Contrast-enhanced computerised tomogram of the abdomen and pelvis showing multiple cysts in almost all segments of the liver, double rim and no enhancement

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  Discussion Top


PLA is a space-occupying lesion in the liver associated with high morbidity and mortality. It is a rare condition of the liver showing significant geographic variation between 2.3 cases per 100,000 in North America and 275.4 cases per 100,000 population in Taiwan.[3]

Common risk factors for the condition include underlying hepatobiliary or pancreatic disease,[4] gastrointestinal malignancy,[5],[6] diabetes mellitus[7] and old age. The patient in our case did not have any of these risk factors for PLA except alcohol consumption for a long period. Alcoholism as a risk factor for the development of PLA has been shown in few studies.[8]

The microbiology of PLA is usually a mixture of enteric flora including facultative and obligate anaerobes.[9] K. pneumoniae is the most common organism isolated from PLA followed by Escherichia coli.[10] K. pneumoniae is a Gram-negative, gas-producing, capsulated, non-motile, enteric bacillus widely found in nature and as normal flora in the human intestine and oral cavity. It can cause infections of the liver, lung, urinary tract and abdominal cavity. Most infections with K. pneumoniae are severe and life threatening, especially bloodstream infections and multiple invasive abscesses.[9] The bacteria isolated in this case was multidrug-resistant K. pneumoniae, resistant to more than three groups of antibiotics. The susceptibility of bacteria to antibiotics in vivo is not always the same as the results in vitro but can be influenced by many factors, such as host immunology and biofilm formation.[11]. In this case, the patient responded well to the medical management with Carbapenems which was found sensitive in the antimicrobial susceptibility test.

Blood cultures from patients with PLA are positive in 30%–60% of cases, although rates are higher with K. pneumoniae. In this patient, blood culture was sterile probably due to inhibitory effects of antibiotics that the patient has already received for about five days prior to the collection of blood sample.

Laboratory evaluation in patients with PLA often reveals leucocytosis, normocytic anaemia, hypoalbuminemia and prolonged prothrombin time. Elevated inflammatory markers, including ESR and C-reactive protein, are sensitive but non-specific for diagnosis. An elevated alkaline phosphatase is the most commonly observed laboratory abnormality, occurring in up to 90% of patients. Approximately 50%–65% of patients may have elevated aspartate and alanine aminotransferases and total bilirubin levels. The patient in our case showed only neutrophilic leucocytosis and an elevated ESR. Liver enzymes including alkaline phosphatase were found within normal limits.

Computed tomography (CT) and ultrasound are the preferred imaging modalities for diagnosis of PLA. PLAs appear as hypo- or hyperechoic lesions with internal debris on ultrasound and non-enhancing hypodense lesions with rim enhancement on CT.

It is important to differentiate amoebic or PLA clinically as the treatment differs significantly. A combination of clinical, laboratory and imaging parameters can help in making a provisional clinical diagnosis of amoebic or PLA. In a retrospective study of 577 adults (2000–2016) with liver abscess, presumptive diagnosis of pyogenic abscess and amoebic abscess was made in 18% (n = 106) and 82% (n = 471), respectively, based on clinical and laboratory parameters. The study observed that patients older than 50 years, with pulmonary findings on physical examination, multiple abscesses in imaging and amoebic serology titres <1:256 IU, are more likely to have a PLA.[12]

Management of PLA has dramatically improved over the past three decades due to advances in diagnostic and interventional radiology. Percutaneous drainage, along with targeted antimicrobial therapy, remains the mainstay of treatment. Despite improvements in therapeutic modalities, PLA remains a serious condition with a high morbidity and a mortality rate of up to 60%. Our patient responded with percutaneous drainage and medical management.


  Conclusion Top


PLA can occur in immunocompetent individuals without any morbidity, and a high index of suspicion and diligent search by the microbiologist is the key to successful management of the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver II. An analysis of forty-seven cases with review of the literature. Am J Surg 1938;XL: 292-319.  Back to cited text no. 1
    
2.
Singh A, Banerjee T, Kumar R, Shukla SK. Prevalence of cases of amebic liver abscess in a tertiary care centre in India: A study on risk factors, associated microflora and strain variation of Entamoeba histolytica. PLoS One 2019;14:e0214880.  Back to cited text no. 2
    
3.
Chen CH, Wu SS, Chang HC, Chang YJ. Initial presentations and final outcomes of primary pyogenic liver abscess: A cross-sectional study. BMC Gastroenterol 2014;14:133.  Back to cited text no. 3
    
4.
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. 4
    
5.
Huang CJ, Pitt HA, Lipsett PA, Osterman FA Jr., Lillemoe KD, Cameron JL, et al. Pyogenic hepatic abscess. Changing trends over 42 years. Ann Surg 1996;223:600-7.  Back to cited text no. 5
    
6.
Heneghan HM, Healy NA, Martin ST, Ryan RS, Nolan N, Traynor O, et al. Modern management of pyogenic hepatic abscess: A case series and review of the literature. BMC Res Notes 2011;4:80.  Back to cited text no. 6
    
7.
Thomsen RW, Jepsen P, Sørensen HT. Diabetes mellitus and pyogenic liver abscess: Risk and prognosis. Clin Infect Dis 2007;44:1194-201.  Back to cited text no. 7
    
8.
Wang YC, Yang KW, Lee TP, Lin CL, Liaw GW, Hung DZ, et al. Increased risk of pyogenic liver abscess in patients with alcohol intoxication: A population-based retrospective cohort study. Alcohol 2017;64:23-8.  Back to cited text no. 8
    
9.
Bosanko NC, Chauhan A, Brookes M, Moss M, Wilson PG. Presentations of pyogenic liver abscess in one UK centre over a 15-year period. J R Coll Physicians Edinb 2011;41:13-7.  Back to cited text no. 9
    
10.
Cerwenka H. Pyogenic liver abscess: Differences in etiology and treatment in Southeast Asia and Central Europe. World J Gastroenterol 2010;16:2458-62.  Back to cited text no. 10
    
11.
Xu M, Fu Y, Kong H, Chen X, Chen Y, Li L, et al. Bloodstream infections caused by Klebsiella pneumoniae: Prevalence of blaKPC, virulence factors and their impacts on clinical outcome. BMC Infect Dis 2018;18:358.  Back to cited text no. 11
    
12.
Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA. Features distinguishing amoebic from pyogenic liver abscess: A review of 577 adult cases. Trop Med Int Health 2004;9:718-23.  Back to cited text no. 12
    


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