Spotlight Case: Far-East Movement

  • author profile pictureSteven Yeh, MD
  • author profile pictureJohn D. Kim, MD, FACP
  • author profile pictureBrandon B. Johnson, MD
  • author profile picturePurnima S. Patel, MD

Case history

A 57-year-old Korean male diabetes patient with a history of cholangitis and choledocholithiasis underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting 2 months prior to presentation. One month following the initial procedure, persistence of a common bile duct stone prompted repeat ERCP with biliary stent repositioning.

Over the ensuing week, the patient developed abdominal pain, fever, and chills. He also complained of a 24-hour history of vision loss, pain, and redness in the right eye.

The patient was referred to the Emory University Hospital emergency department, where he also received an ophthalmology consultation.

Visual acuity was counting fingers at 3 feet in the right eye and 20/20 in the left eye. A relative afferent pupillary defect was observed in the right eye. Slit-lamp examination showed 4+ anterior chamber cell and a 1 mm hypopyon in the right eye. Funduscopic examination showed 2+ vitreous haze and a yellow subretinal lesion with overlying hemorrhage involving the temporal macula (Figure 1). The left eye was normal.
 

Figure 1: Fundus photograph shows 1.9 mm x 9.5 mm x 10.1 mm yellow subretinal lesion with subretinal hemorrhage on the convexity of the abscess.
 

What’s your diagnosis?

The patient was diagnosed with Klebsiella pneumoniae endogenous endophthalmitis. This diagnosis was based on:

  • History of liver abscess
  • K pneumoniae sepsis
  • Asian ethnicity
  • Characteristic fundus findings
     

Management

The patient was treated with intravitreal tap and injection of vancomycin 1 mg/0.1 cc, ceftazidime 2.25 mg/0.1 cc, and voriconazole 100 µg/0.1 cc. The patient was also started on prednisolone acetate 1% 4 times daily and atropine 1% 2 times daily. The patient was admitted for intravenous Zosyn (piperacillin/tazobactam 3.375 g, Pfizer, Inc, New York, NY) every 8 hours and vancomycin 1.25 g every 12 hours, following infectious diseases consultation.

Three days after the initial vitreous tap and injection, the patient reported decreased pain and the hypopyon had resolved. B-scan ultrasound showed that the subretinal abscess had increased in size from 1.9 mm x 9.5 mm x 10.1 mm to 3.1 mm x 13.1 mm x 12.6 mm (Figures 2 and 3). Repeat injections of vancomycin 1 mg/0.1 cc and ceftazidime 2.25 mg/0.1 cc were performed, and the potential need for a vitrectomy was discussed with the patient. Because of the patient’s persistent fever and the need for a liver drain placement, vitrectomy was deferred.

Figure 2: Fundus photograph 3 days after initial tap and inject shows vitreous hemorrhage with increased inflammation.

Two separate blood cultures, a urine culture, and an abdominal fluid culture showed K pneumoniae, which was sensitive to amikacin, ceftazidime, piperacillin/tazobactam, and levofloxacin but resistant to ampicillin. Intravenous ceftaroline 600 mg every 12 hours was initiated on hospital day 5 and continued until hospital day 12.

The patient’s condition gradually improved, although a subretinal lesion persisted. Intravitreal amikacin 400 µg/0.1 cc and ceftazidime 2.25 mg/0.1 cc were administered on hospital day 12, and the patient was transitioned to oral moxifloxacin 400 mg daily.

The subretinal abscess became more consolidated over time. However, a combined tractional and exudative detachment developed 6 weeks following initial admission (Figure 4), which prompted pars plana vitrectomy (PPV), membrane peel, endolaser, and silicone oil instillation.
By the 6-month (final) follow-up, the patient’s visual acuity remained counting fingers at 3 feet and the retina remained attached, with a macular chorioretinal scar (Figure 5).

Figure 3: The subretinal lesion had enlarged to 3.1 mm x 13.1 mm x 12.6 mm.

 

 

 

  

Discussion

Klebsiella pneumoniae invasive liver abscess syndrome, initially reported in Taiwan, is a distinct disease entity that has been reported with increasing frequency over the past 2 decades in Asia, including:

  • Hong Kong
  • Singapore
  • South Korea
  • Vietnam

Klebsiella pneumoniae infection is the major cause of pyogenic liver abscesses in[1]:

  • Hong Kong

    Figure 4: Following systemic and intravitreal injections, the subretinal lesion continued to resolve; however, a combined tractional and exudative retinal detachment developed.

  • Singapore
  • South Korea
  • Taiwan

According to its clinical definition, invasive liver abscess syndrome is the presence of a K pneumoniae liver abscess in association with extrahepatic complications, including:

  • Central nervous system (CNS) involvement
  • Necrotizing fasciitis
  • Endogenous endophthalmitis

In microbiologic terms, this syndrome may also be defined by the presence of K1 or K2 serotypes of K pneumoniae. K1 and K2 serotypes confer a hypermucoviscous phenotype, which is thought to increase the invasiveness of K pneumoniae. Specifically, the K1 and K2 strains have a high prevalence of resistance to phagocytosis and intracellular killing by neutrophils and bactericidal components of patient serum, which portends a poorer systemic prognosis.[1]

Systemic clinical manifestations of K pneumoniae liver abscesses include:

  • Fevers
  • Chills
  • Abdominal pain
  • Nausea
  • Vomiting

Abnormal laboratory findings include:

  • Leukocytosis
  • Thrombocytopenia
  • Hyperglycemia
  • Elevated C-reactive protein (CRP)
  • Liver function abnormalities

Figure 5: At final follow-up, the retina was successfully attached under silicone oil. Visual acuity is limited by the macular scar, but the liver abscess resolved.

Endogenous endophthalmitis and meningitis are the 2 most common extrahepatic manifestations of invasive liver abscess syndrome. Sheu et al reported their retrospective review of 20 years of medical records, in which they identified endophthalmitis in 42 patients (53 eyes) of 602 K pneumoniae liver abscess patients in Taiwan (mean age of 61).[2] The patients had been admitted between 1991 and 2009, and 11 of them presented with bilateral disease.

Of the 53 eyes studied, 19 eyes (36%) had counting fingers or better vision at final follow-up. Diabetes was associated with the development of endophthalmitis (P = .003) and poor visual outcome (P = .019). Currently available retrospective reviews of this disease syndrome suggest that endophthalmitis occurs with an incidence ranging from 3%-11%.[2-4]

This invasive liver abscess syndrome is increasingly recognized in Asian countries, and although it is rare in North America, K pneumoniae endogenous endophthalmitis has been observed in Asian patients.[5-7] The optimal management of this condition has not been defined, but a combination of systemic and intravitreal antibiotics has been successfully employed in some reports.[5] Early vitrectomy has also been advocated as a management option by some authors[8]; however, the overall systemic health of the patient, particularly in the setting of K pneumoniae sepsis, as observed in the patient, warrants consideration prior to vitrectomy.

 
Take-home points

  • Klebsiella pneumoniae is a cause of endogenous endophthalmitis in association with a distinct invasive liver abscess syndrome. It has been described predominantly in Asian countries.  
  • K1 and K2 serotypes of K pneumoniae confer a hypermucoviscous phenotype which contributes to the invasive nature of this syndrome, possibly resulting in metastatic foci to the CNS, eye, and other organs.
  • Recognition of K pneumoniae as a cause of endophthalmitis in the setting of a liver abscess should prompt early and aggressive antimicrobial therapy, as K pneumoniae endophthalmitis has been associated with poor visual outcomes in the majority of patients. 
     

References

  1. Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12(11):881-887. doi:10.1016/S1473-3099(12)70205-0.
  2. Sheu SJ, Kung YH, Wu TT, Chang FP, Horng YH. Risk factors for endogenous endophthalmitis secondary to Klebsiella pneumoniae liver abscess: 20-year experience in Southern Taiwan. Retina. 2011;31(10):2026-2031. doi:10.1097/IAE.0b013e31820d3f9e.
  3. Sng CC, Jap A, Chan YH, Chee SP. Risk factors for endogenous Klebsiella endophthalmitis in patients with Klebsiella bacteraemia: a case-control study [published online February 1, 2008]. Br J Ophthalmol. 2008;92(5):673-677. doi:10.1136/bjo.2007.132522.
  4. Yang CS, Tsai HY, Sung CS, Lin KH, Lee FL, Hsu WM. Endogenous Klebsiella endophthalmitis associated with pyogenic liver abscess. Ophthalmol. 2007;114(5):876-880.
  5. Kashani AH, Eliott D. Bilateral Klebsiella pneumoniae (K1 serotype) endogenous endophthalmitis as the presenting sign of disseminated infection. Ophthalmic Surg Lasers Imaging. 2011;42.Online:e12-e14. doi:10.3928/15428877-20110203-02.
  6. Kashani AH, Eliott D. The emergence of Klebsiella pneumoniae endogenous endophthalmitis in the USA: basic and clinical advances. J Ophthalmic Inflamm Infect. 2013;3(1):28. doi:10.1186/1869-5760-3-28.
  7. Scott IU, Matharoo N, Flynn HW Jr, Miller D. Endophthalmitis caused by Klebsiella species. Am J Ophthalmol. 2004;138(4):662-663.
  8. Yoon YH, Lee SU, Sohn JH, Lee SE. Result of early vitrectomy for endogenous Klebsiella pneumoniae endophthalmitis. Retina. 2003;23(3):366-370.

Financial disclosures

Dr. Yeh - ABBOTT LABORATORIES: Investigator, Grants; BAUSCH + LOMB, INC: Consultant, Honoraria; CLEARSIDE: Advisory Board, Honoraria; NOVARTIS PHARMACEUTICALS CORPORATION: Investigator, Grants; SANTEN: Advisory Board, Honoraria.

Dr. Johnson - None.

Dr. Kim - None.

Dr. Patel - None.

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