Bilateral osteomyelitis and liver abscess caused by hypervirulent Klebsiella pneumoniae- a rare clinical manifestation (case report)

Abstract

BackgroundHypervirulent strains of Klebsiella pneumoniae are a recognized cause of a distinct invasive syndrome that results in pyogenic liver abscesses and metastatic complications, particularly in the Asia Pacific region. Reports of hypervirulent K.pneumoniae in Europe, the Americas and Australia indicate worldwide spread. We present a case of multi-focal osteomyelitis, a rarely described complication of hypervirulent K.pneumoniae in the medical literature. The prevalence of this condition in countries outside Asia may be expected to rise with increasing travel.Case presentationA 20-year-old Chinese man residing in Australia for 2 years presented with a 2-week history of gradually worsening leg pain preceded by 2 weeks of constitutional symptoms. Imaging with computerized axial tomography (CT) and other modalities revealed bilateral tibial lesions described as lattice-like linear lucencies involving the cortices with scalloping of the outer involved cortex. Cultures of tissue from a left tibial bone biopsy were positive cultures for K.pneumoniae. Whole-genome sequencing identified the isolate as K1 serotype ST23, a well-recognized hyper virulent strain capable of causing invasive disease. An abdominal CT revealed a 27x22mm liver abscess. The patient had no other metastatic manifestations of the disease, and responded to 6 weeks of intravenous ceftriaxone followed by 3 months of oral Ciprofloxacin.ConclusionsIncreased awareness of the manifestations and subsequent management of hyper virulent strains of K.pneumoniae by clinicians is important to assist early recognition and help minimize serious sequelae. Cases with overseas links, such as previous residence in the Asia Pacific area, are at higher risk for infection with the hyper virulent strain. This case highlights the need for clinicians to be able to recognize this important disease, especially in patients with the right epidemiological links, and to investigate and treat appropriately to prevent severe metastatic complications.

Hypervirulent Klebsiella pneumoniae – clinical and molecular perspectives

“…Global dissemination of hvKp. Following early reports of hvKp in Asia, it is now apparent that hvKp has spread globally, including India [163,164], Europe [32,34,35,37,[165][166][167][168], Australia [169,170] and the United States [5,30,31,36,53,171,172] and healthcare providers worldwide should recognize the threat of community-acquired hvKp in otherwise healthy individuals. The rise of hospital-acquired hvKp which may manifest in different presentations, and the convergence of multidrug resistance (MDR) and virulence either in as well as bla SHV-1 and fosA [182] AR, antimicrobial resistance; bla, beta-lactamase provides resistance to penicillins, first-and second-generation cephalosporins; bla CTX-M-24, bla CTX-M-3 and bla CTX-M-4 , ESBLs with particular activity against cefotaxime; bla KPC-2, bla (K. pneumoniae carbapenem resistance) with carbapenemase activity; bla NDM-1 , bla (New Delhi metallo-bla) with carbapenemase activity; bla OXA-32 and bla OXA-9 , ESBLs with particular activity against oxacillin; bla SHV-36 and bla SHV-11 , ESBLs; bla TEM-1A, bla TEM-1, and bla TEM-53 , ESBLs; dfrA14, trimethoprim resistance gene; ESBL, extended-spectrum betalactamase provides additional resistance to monobactams and third-generation cephalosporins; fosA, fosfomycin resistance gene; kb, kilobase, length of DNA molecule; ompK35/36, outer membrane porins that allow entry carbapenems and cephalosporins, reduced expression increases resistance; oqxAB, resistance to olaquindox and some quinolones.…”

“…Global dissemination of hvKp. Following early reports of hvKp in Asia, it is now apparent that hvKp has spread globally, including India , Europe , Australia and the United States and healthcare providers worldwide should recognize the threat of community‐acquired hvKp in otherwise healthy individuals. The rise of hospital‐acquired hvKp which may manifest in different presentations, and the convergence of multidrug resistance (MDR) and virulence either in cKp or hvKp strains, is particularly concerning.…”

Global Evolution of Pathogenic Bacteria With Extensive Use of Fluoroquinolone Agents

“…Moreover it is well-established that strains from the most virulent K. pneumoniae sequence type ST23 remain less resistant to antibiotics -primarily to fluoroquinolonesthan isolates from the MDR major international STs (Cejas et al, 2014;Qu et al, 2015;Cheong et al, 2016;Yan et al, 2016;Chen Y.T. et al, 2017;Ku et al, 2017;Lu et al, 2017;Sturm et al, 2018;Shen et al, 2019). Moreover, similarly to the most virulent MRSA clone, ST121, no high-level resistance to fluoroquinolones has been reported in any ST23 K. pneumoniae strain to date.…”

Liver Abscess and Septic Pulmonary Dissemination by Klebsiella pneumoniae in a Hispanic Male: A Case Report

“…Although there is no established definition of KPIS [7,8], it is classically described as a clinical syndrome rotizing fasciitis [36], vertebral discitis [37], multifocal osteomyelitis [38], prostate abscess [39], splenic, neck, cerebral, and psoas muscle abscesses, otitis media, and arthritis [40]. In our case, the patient presented with liver abscess and septic pulmonary embolism which is considered in the literature as a rare extrahepatic complication [41].…”