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Klebsiella hepatic abscess

Case contributed by Ammar Ashraf
Diagnosis certain

Presentation

Right upper quadrant pain, low-grade fever, and fatigue for the last 8 days. History of uncontrolled type II diabetes mellitus, hypertension, and bronchial asthma.

Patient Data

Age: 65 years
Gender: Female
ultrasound

8 x 8 cm heterogeneous mixed echogenicity right hepatic lobe lesion without any  internal vascularity.

ct

8.5 x 9.5 cm heterogeneous multi-septated/multiloculated cystic mildly enhancing lesion in the right hepatic lobe (segment VIII & VII) which is likely a pyogenic liver abscess. No calcifications or air densities are appreciable in it. Two small non-obstructive calculi and a few tiny simple cortical cysts are seen in the left kidney. Minimal right pleural effusion and bilateral basal atelectatic changes.

Aspiration & catheter drainage

ultrasound

About 80 ml of thick greenish pus mixed with blood was aspirated under ultrasound guidance. Following aspiration, an 8 French pigtail catheter was inserted in the liver abscess for drainage. 

FU US after 4 dyas

ultrasound

Mild interval reduction is noted in the size of the right hepatic lobe abscess when compared with the previous imaging. An external drainage catheter is seen within it.

Case Discussion

Laboratory investigations showed elevated CRP=186 mg/L (1.20), WBC=15 x 109/L (4.00-11.00), LDH=449 U/L (125-220), and alkaline phosphatase=450 U/L (40-150). 

Culture and sensitivity of the aspirated pus from the hepatic abscess showed heavy growth of Klebsiella pneumoniae, which was resistant to ampicillin and sensitive to cefalotin,  ciprofloxacin, gentamicin, piperacillin/tazobactam, & trimethoprim/sulfa.

Gram negative mixed aerobic and anaerobic organisms (with Escherichia coli being the most frequent agent) are the most common bacterial agents responsible for the pyogenic liver abscess (PLA). Klebsiella pneumoniae, a gram-negative organism, is an emerging common cause of PLA, particularly in patients with poorly controlled diabetes mellitus and without any pre-existing liver disease. Some extrahepatic metastatic infections have been reported in patients with Klebsiella liver abscess which are endophthalmitis, meningitis/brain abscess, necrotizing fasciitis, septic pulmonary emboli/ lung abscess, splenic abscess, septic arthritis, and osteomyelitis, etc 1.

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