The Journal of Emergency Medicine, Vol. 48, No. 5, pp. 548–550, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.035
Clinical Communications: Adults A RARE PRESENTATION OF SYSTEMIC EMPHYSEMATOUS INFECTIONS SECONDARY TO KLEBSIELLA PNEUMONIAE BACTEREMIA IN A DIABETIC PATIENT Daniel Lai, MD,* Kuang-Chau Tsai, MD,* Mau-Sheng Lin, MD,* Tzu-Kai Lin, MD,* Chieh-Min Fan, MD,* Hsiao-Chun Chang, MD,† and Jen-Tang Sun, MD* *Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan and †Department of Urology, Far Eastern Memorial Hospital, Taipei, Taiwan Reprint Address: Jen-Tang Sun, MD, Department of Emergency Medicine, Far Eastern Memorial Hospital, 21, Sec. 2, Nan-Ya South Road, Pan-Chiao, New Taipei City, Taiwan
, Abstract—Background: Diabetic patients are at an increased risk of developing Klebsiella pneumoniae pyogenic liver abscess (KLA) and its extrahepatic complications. This is the first case report depicting the concurrence of pyogenic liver abscess, emphysematous pyelonephritis, and necrotizing fasciitis in 1 patient. Case Report: A 29-year-old male with a history of poorly controlled diabetes presented to the emergency department with lower back pain and right lower leg pain for 1 week. Abdominal ultrasound and computed tomography revealed pyogenic liver abscess, bilateral emphysematous pyelonephritis, and right lower-extremity necrotizing fasciitis. The patient then received emergent fasciectomy and bilateral percutaneous nephrostomy. K. pneumoniae was isolated from the blood culture, right nephrostomy tube, and right lower-extremity wound, indicating that it was the cause of these infections. Why Should an Emergency Physician Be Aware of This?: In diabetic patients diagnosed with KLA, an emergency physician must perform thorough examinations to exclude potential systemic extrahepatic infections. KLA seeding infections are usually hematogenous in origin, as bacteremia is significantly more common in KLA than other pyogenic liver abscess. Documented sites of KLA seeding include eyes, lungs, kidneys, brain, meninges, soft tissues, and bone. Ó 2015 Elsevier Inc.
INTRODUCTION Before 1980, Escherichia coli was the most common causative agent for pyogenic liver abscess (1,2). More recently, Klebsiella pneumoniae has become more prevalent, and is now the leading cause of pyogenic liver abscess in Taiwan and United States (1,2). K. pneumoniae pyogenic liver abscess (KLA) is associated with a high percentage of bacteremia and extrahepatic complications (1,2). We present a case of a 29-year-old diabetic man who was diagnosed with bilateral emphysematous pyelonephritis and right lower-extremity necrotizing fasciitis (NF) subsequent to bloodstream infection of KLA. CASE REPORT A 29-year-old male, with history of poorly controlled type 2 diabetes mellitus (DM) for 10 years, visited our emergency department due to lower back pain and right lower-extremity numbness for >1 week. Upon arrival, his body temperature was 37.6 C. The rest of his vital signs were normal. Physical examination revealed left costovertebral tenderness and right medial ankle swelling with crepitus. Abdomen was soft without focal tenderness. Laboratory tests showed elevated leukocytes
, Keywords—Klebsiella pneumoniae; pyogenic liver abscess; bloodstream infection; emphysematous pyelonephritis; necrotizing fasciitis; diabetes mellitus
RECEIVED: 22 April 2014; FINAL SUBMISSION RECEIVED: 23 October 2014; ACCEPTED: 21 December 2014 548
Systemic Emphysematous Infections in a Diabetic Patient
549
Figure 2. Computed tomography discloses abnormal gas accumulation (white arrow) at bilateral renal parenchyma.
DISCUSSION
Figure 1. Abdominal echo showing a hypodense lesion at the S4 of liver (white arrow), which also appeared on noncontrast computed tomography of the abdomen (not shown).
(41.2 103/mL), blood glucose (653 mg/dL), and creatinine (2.08 mg/dL). Bedside sonogram revealed air and fluid in the subcutaneous and muscle layer of the right lower extremity. Abdominal ultrasound showed an abscess formation at S4 of the liver (Figure 1). Noncontrast computed tomography (CT) of abdomen and lower extremities disclosed gas and fluid accumulation at bilateral kidney (Figure 2), as well as abnormal air collection at the posterior compartment of right leg, with extension to the thigh region (Figure 3). Diagnosis of liver abscess, bilateral emphysematous pyelonephritis, and right lowerextremity NF was made. Subsequently, the patient received emergent bilateral percutaneous nephrostomy and fasciectomy of the right lower leg. K. pneumoniae was isolated from the blood cultures, right nephrostomy tube, and right lower-extremity wound. The patient received imipenem and teicoplanin, as well as second debridement of the right lower extremity 10 days after the first fasciectomy. Follow-up of abdominal ultrasound showed resolution of the liver abscess. The patient was discharged on the 40th day of hospitalization in stable condition.
Diabetic individuals are at increased risk of developing pyogenic liver abscess, in particular, KLA (2,3). DM is also an independent risk factor for KLA extrahepatic metastases (4). Extrahepatic seeding sites of KLA that have been documented include eyes, lungs, kidneys,
Figure 3. Computed tomography discloses abnormal air collection in the intermuscular spaces at the posterior compartment of right leg (white arrow) with extension to the thigh region.
550
skin/soft tissue, brain/meninges, and bones (2–4). Metastatic endophthalmitis is the most common involved complication, and often results in blindness or decreased vision of the affected eye (4,5). Hematogenous route is responsible for the disseminated seeding because bacteremia, as high as 95% described in one study, is closely associated with KLA (2,5). This differs from non-Klebsiella liver abscess, in which bacteremia is found in only 50% of cases (1,2). In addition to KLA, our patient also has bilateral emphysematous pyelonephritis (EPN) and NF of the right lower extremity. EPN is an uncommon but lifethreatening infection that occurs almost exclusively in DM patients (5,6). It is characterized by necrotizing infection of the renal parenchyma, collecting system, or perirenal tissue with gas accumulation. Similar to pyogenic liver abscess, E. coli and K. pneumoniae are the most common causative organisms (5,6). Common clinical presentations include fever, flank pain, nausea, vomiting, and acute renal failure (5). CT is important for early diagnosis and prognosis. Two types have been described based on CT imaging (7). Type 1 is characterized by destruction of renal parenchymal tissue with presence of mottled gas, and type 2 is characterized by confined gas within the abscess that is associated with renal and perinephric fluid collection of the renal pelvis (7). Current treatment options include antibiotics alone, antibiotics with percutaneous nephrostomy, and nephrectomy, depending on the extent of infection on CT imaging (5). NF is a life-threatening and deep-seated infection of soft tissue, including fascia (8,9). Predisposing factors include old age, DM, alcoholism, and male sex. Early symptoms are nonspecific, such as pain, erythema, increased heat, and swelling, and may mimic those of nonsevere soft-tissue infections. Pain out of proportion to local findings is an alarming sign and should raise suspicion for NF. Examination may reveal ecchymosis that rapidly progress into hemorrhagic bullae. NF is categorized into two types, depending on the microbiologic profile. Type 1 is characterized by polymicrobial infection and usually occurs in chronically ill patients. Type 2 is an infection of Group A Streptococcus or Staphylococcus origin and can occur in patients of all ages, with or without underlying medical conditions. Klebsiella species, as in this case, are also common causative organisms. Treatment involves immediate and extensive fasiectomy with empirical broad-spectrum antibiotics. The rare combinations of EPN and NF have been reported in few previous cases. In one case, the superior
D. Lai et al.
and inferior lumbar triangles, which are sites of anatomical weakness in the abdominal wall due to absence of external muscle layer, serves as the route of spread from EPN to ipsilateral NF (8). In another report, extension through the iliopsoas compartment was the cause of this combined infection (9). In our case, we believe that hematogenous seeding rather than retroperitoneal spread is responsible for linking these two infections, for two reasons. First, direct invasion of the retroperitoneal space to the right lower extremity was absent on noncontrast CT. Second, our patient’s case is one of diabetes with KLA and Klebisella bacteremia; KLA is known for its extrahepatic metastasis via bloodstream infection, especially in diabetic individuals. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? To our knowledge, this is the first case report on the concurrence of KLA, bilateral EPN, and right lower-extremity NF in 1 patient. Multiple extrahepatic infections of KLA have been reported previously. These infections are usually severe and are usually hematogenous in origin. In countries where KLA is common, such as Taiwan, emergency physicians must be aware of potential and lethal extrahepatic spread of KLA, especially in the diabetic population. REFERENCES 1. Pope JV, Teich DL, Clardy P, et al. Klebsiella Pneumoniae liver abscess: an emerging problem in North America. J Emerg Med 2011; 41:e103–5. 2. Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella Pneumoniae as a primary pathogen: an emerging disease with unique clinical characteristics. Am J Gastroenterol 2005;100: 323–31. 3. Tatsuta T, Wada T, Chinda D, et al. A case of gas-forming liver abscess with diabetes mellitus. Intern Med 2011;50:2329–32. 4. Chen S-C, Lee Y-T, Lai K-C, et al. Risk factors for developing metastatic infection from pyogenic liver abscesses. Swiss Med Wkly 2006;136:119–26. 5. Huang J-J, Tseng C-C. Emphysematous pyelonephritis. Arch Intern Med 2000;160:797–805. 6. Balicco B, Manzoni D, Ancora C. A case of fatal emphysematous pyelonephritis presenting as lower limb gaseous gangrene. Minerva Anestesiol 2009;75:665–7. 7. Wan YL, Lee TY, Bullard MJ, et al. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996;198:433–8. 8. Ishigami K, Bolton-Smith JA, DeYoung BR, et al. Necrotizing fasciitis caused by xanthogranulomatous and emphysematous pyelonephritis: importance of the inferior lumbar triangle pathway. AJR Am J Roentgenol 2004;183:1708–10. 9. Yasuda T, Tani Y. Necrotizing fasciitis caused by emphysematous pyelonephritis through iliopsoas abscess. J Orthop Sci 2011;16:832–5.
http://dx.doi.org/10.1016/j.jemermed.2014.12.035
Clinical Communications: Adults A RARE PRESENTATION OF SYSTEMIC EMPHYSEMATOUS INFECTIONS SECONDARY TO KLEBSIELLA PNEUMONIAE BACTEREMIA IN A DIABETIC PATIENT Daniel Lai, MD,* Kuang-Chau Tsai, MD,* Mau-Sheng Lin, MD,* Tzu-Kai Lin, MD,* Chieh-Min Fan, MD,* Hsiao-Chun Chang, MD,† and Jen-Tang Sun, MD* *Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan and †Department of Urology, Far Eastern Memorial Hospital, Taipei, Taiwan Reprint Address: Jen-Tang Sun, MD, Department of Emergency Medicine, Far Eastern Memorial Hospital, 21, Sec. 2, Nan-Ya South Road, Pan-Chiao, New Taipei City, Taiwan
, Abstract—Background: Diabetic patients are at an increased risk of developing Klebsiella pneumoniae pyogenic liver abscess (KLA) and its extrahepatic complications. This is the first case report depicting the concurrence of pyogenic liver abscess, emphysematous pyelonephritis, and necrotizing fasciitis in 1 patient. Case Report: A 29-year-old male with a history of poorly controlled diabetes presented to the emergency department with lower back pain and right lower leg pain for 1 week. Abdominal ultrasound and computed tomography revealed pyogenic liver abscess, bilateral emphysematous pyelonephritis, and right lower-extremity necrotizing fasciitis. The patient then received emergent fasciectomy and bilateral percutaneous nephrostomy. K. pneumoniae was isolated from the blood culture, right nephrostomy tube, and right lower-extremity wound, indicating that it was the cause of these infections. Why Should an Emergency Physician Be Aware of This?: In diabetic patients diagnosed with KLA, an emergency physician must perform thorough examinations to exclude potential systemic extrahepatic infections. KLA seeding infections are usually hematogenous in origin, as bacteremia is significantly more common in KLA than other pyogenic liver abscess. Documented sites of KLA seeding include eyes, lungs, kidneys, brain, meninges, soft tissues, and bone. Ó 2015 Elsevier Inc.
INTRODUCTION Before 1980, Escherichia coli was the most common causative agent for pyogenic liver abscess (1,2). More recently, Klebsiella pneumoniae has become more prevalent, and is now the leading cause of pyogenic liver abscess in Taiwan and United States (1,2). K. pneumoniae pyogenic liver abscess (KLA) is associated with a high percentage of bacteremia and extrahepatic complications (1,2). We present a case of a 29-year-old diabetic man who was diagnosed with bilateral emphysematous pyelonephritis and right lower-extremity necrotizing fasciitis (NF) subsequent to bloodstream infection of KLA. CASE REPORT A 29-year-old male, with history of poorly controlled type 2 diabetes mellitus (DM) for 10 years, visited our emergency department due to lower back pain and right lower-extremity numbness for >1 week. Upon arrival, his body temperature was 37.6 C. The rest of his vital signs were normal. Physical examination revealed left costovertebral tenderness and right medial ankle swelling with crepitus. Abdomen was soft without focal tenderness. Laboratory tests showed elevated leukocytes
, Keywords—Klebsiella pneumoniae; pyogenic liver abscess; bloodstream infection; emphysematous pyelonephritis; necrotizing fasciitis; diabetes mellitus
RECEIVED: 22 April 2014; FINAL SUBMISSION RECEIVED: 23 October 2014; ACCEPTED: 21 December 2014 548
Systemic Emphysematous Infections in a Diabetic Patient
549
Figure 2. Computed tomography discloses abnormal gas accumulation (white arrow) at bilateral renal parenchyma.
DISCUSSION
Figure 1. Abdominal echo showing a hypodense lesion at the S4 of liver (white arrow), which also appeared on noncontrast computed tomography of the abdomen (not shown).
(41.2 103/mL), blood glucose (653 mg/dL), and creatinine (2.08 mg/dL). Bedside sonogram revealed air and fluid in the subcutaneous and muscle layer of the right lower extremity. Abdominal ultrasound showed an abscess formation at S4 of the liver (Figure 1). Noncontrast computed tomography (CT) of abdomen and lower extremities disclosed gas and fluid accumulation at bilateral kidney (Figure 2), as well as abnormal air collection at the posterior compartment of right leg, with extension to the thigh region (Figure 3). Diagnosis of liver abscess, bilateral emphysematous pyelonephritis, and right lowerextremity NF was made. Subsequently, the patient received emergent bilateral percutaneous nephrostomy and fasciectomy of the right lower leg. K. pneumoniae was isolated from the blood cultures, right nephrostomy tube, and right lower-extremity wound. The patient received imipenem and teicoplanin, as well as second debridement of the right lower extremity 10 days after the first fasciectomy. Follow-up of abdominal ultrasound showed resolution of the liver abscess. The patient was discharged on the 40th day of hospitalization in stable condition.
Diabetic individuals are at increased risk of developing pyogenic liver abscess, in particular, KLA (2,3). DM is also an independent risk factor for KLA extrahepatic metastases (4). Extrahepatic seeding sites of KLA that have been documented include eyes, lungs, kidneys,
Figure 3. Computed tomography discloses abnormal air collection in the intermuscular spaces at the posterior compartment of right leg (white arrow) with extension to the thigh region.
550
skin/soft tissue, brain/meninges, and bones (2–4). Metastatic endophthalmitis is the most common involved complication, and often results in blindness or decreased vision of the affected eye (4,5). Hematogenous route is responsible for the disseminated seeding because bacteremia, as high as 95% described in one study, is closely associated with KLA (2,5). This differs from non-Klebsiella liver abscess, in which bacteremia is found in only 50% of cases (1,2). In addition to KLA, our patient also has bilateral emphysematous pyelonephritis (EPN) and NF of the right lower extremity. EPN is an uncommon but lifethreatening infection that occurs almost exclusively in DM patients (5,6). It is characterized by necrotizing infection of the renal parenchyma, collecting system, or perirenal tissue with gas accumulation. Similar to pyogenic liver abscess, E. coli and K. pneumoniae are the most common causative organisms (5,6). Common clinical presentations include fever, flank pain, nausea, vomiting, and acute renal failure (5). CT is important for early diagnosis and prognosis. Two types have been described based on CT imaging (7). Type 1 is characterized by destruction of renal parenchymal tissue with presence of mottled gas, and type 2 is characterized by confined gas within the abscess that is associated with renal and perinephric fluid collection of the renal pelvis (7). Current treatment options include antibiotics alone, antibiotics with percutaneous nephrostomy, and nephrectomy, depending on the extent of infection on CT imaging (5). NF is a life-threatening and deep-seated infection of soft tissue, including fascia (8,9). Predisposing factors include old age, DM, alcoholism, and male sex. Early symptoms are nonspecific, such as pain, erythema, increased heat, and swelling, and may mimic those of nonsevere soft-tissue infections. Pain out of proportion to local findings is an alarming sign and should raise suspicion for NF. Examination may reveal ecchymosis that rapidly progress into hemorrhagic bullae. NF is categorized into two types, depending on the microbiologic profile. Type 1 is characterized by polymicrobial infection and usually occurs in chronically ill patients. Type 2 is an infection of Group A Streptococcus or Staphylococcus origin and can occur in patients of all ages, with or without underlying medical conditions. Klebsiella species, as in this case, are also common causative organisms. Treatment involves immediate and extensive fasiectomy with empirical broad-spectrum antibiotics. The rare combinations of EPN and NF have been reported in few previous cases. In one case, the superior
D. Lai et al.
and inferior lumbar triangles, which are sites of anatomical weakness in the abdominal wall due to absence of external muscle layer, serves as the route of spread from EPN to ipsilateral NF (8). In another report, extension through the iliopsoas compartment was the cause of this combined infection (9). In our case, we believe that hematogenous seeding rather than retroperitoneal spread is responsible for linking these two infections, for two reasons. First, direct invasion of the retroperitoneal space to the right lower extremity was absent on noncontrast CT. Second, our patient’s case is one of diabetes with KLA and Klebisella bacteremia; KLA is known for its extrahepatic metastasis via bloodstream infection, especially in diabetic individuals. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? To our knowledge, this is the first case report on the concurrence of KLA, bilateral EPN, and right lower-extremity NF in 1 patient. Multiple extrahepatic infections of KLA have been reported previously. These infections are usually severe and are usually hematogenous in origin. In countries where KLA is common, such as Taiwan, emergency physicians must be aware of potential and lethal extrahepatic spread of KLA, especially in the diabetic population. REFERENCES 1. Pope JV, Teich DL, Clardy P, et al. Klebsiella Pneumoniae liver abscess: an emerging problem in North America. J Emerg Med 2011; 41:e103–5. 2. Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella Pneumoniae as a primary pathogen: an emerging disease with unique clinical characteristics. Am J Gastroenterol 2005;100: 323–31. 3. Tatsuta T, Wada T, Chinda D, et al. A case of gas-forming liver abscess with diabetes mellitus. Intern Med 2011;50:2329–32. 4. Chen S-C, Lee Y-T, Lai K-C, et al. Risk factors for developing metastatic infection from pyogenic liver abscesses. Swiss Med Wkly 2006;136:119–26. 5. Huang J-J, Tseng C-C. Emphysematous pyelonephritis. Arch Intern Med 2000;160:797–805. 6. Balicco B, Manzoni D, Ancora C. A case of fatal emphysematous pyelonephritis presenting as lower limb gaseous gangrene. Minerva Anestesiol 2009;75:665–7. 7. Wan YL, Lee TY, Bullard MJ, et al. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 1996;198:433–8. 8. Ishigami K, Bolton-Smith JA, DeYoung BR, et al. Necrotizing fasciitis caused by xanthogranulomatous and emphysematous pyelonephritis: importance of the inferior lumbar triangle pathway. AJR Am J Roentgenol 2004;183:1708–10. 9. Yasuda T, Tani Y. Necrotizing fasciitis caused by emphysematous pyelonephritis through iliopsoas abscess. J Orthop Sci 2011;16:832–5.
