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Saint Raphael Healthcare System

Liver abscess presenting as Klebsiella meningitis
F. Braiteh, P. Tailor, M. Golden

A 42-year-old Filipino man with no past medical history presented with a 4-day history of fever to 104F, severe headache and generalized weakness. Physical exam was notable for meningismus and fatigue. Ophthalmologic exam was normal. Lumbar puncture revealed WBC 1700 cells/mm3 (81% segmented, 6% lymphocytes, 13% monocytes), protein of 400 mg %, glucose of 0. Peripheral WBC count was unremarkable, however, he was mildly hyponatremic and thrombocytopenic (platelet 19,000). Head CT scan was unremarkable. HIV serology was negative. Culture of the CSF grew Klebsiella pneumoniae.

Despite therapy with ceftriaxone the patient remained febrile. On hospital day 5, a repeat lumbar puncture showed increasing pleocytosis. A MRI of the head was performed on hospital day 7 because of persistent fever and he was found to have multiple small ring-enhancing lesions consistent with septic emboli. Transthoracic and transesophageal echocardiograms showed normal valve anatomy and no evidence of patent foramen ovale. CT scan of the chest showed a nodule, suggestive of abscess. He began to develop right upper quadrant tenderness along with elevated liver function tests. CT guided aspiration returned frankly purulent material that subsequently grew Klebsiella pneumoniae. Metronidazole was added to the ceftriaxone and one week later a repeat MRI showed increasing edema of the brain lesions, as well as apparent interval development of new lesions. Over the next weeks, however, the patient defervesced, the liver and lung lesions decreased in size and the MRI of the head improved.

Although Klebsiella pneumoniae accounts for up to 33% of the cases of community acquired meningitis in Taiwan, it is a highly unusual pathogen in the United States. We postulate that this patient had a cryptogenic liver abscess, became bacteremic and seeded both his lung and brain with Klebsiella pneumoniae.

Liver abscess in the United States is commonly polymicrobial. Klebsiella pneumoniae liver abscess is a new clinical syndrome that is consistently reported in the medical literature as a serious infectious complication in diabetic patients in Taiwan. Identification of further cases may help to determine if this reported presentation, despite the absence of diabetes mellitus and endophthalmitis, is a variant of the syndrome. This case highlights the importance of looking for a primary focus in previously healthy patients presenting with gram negative rod meningitis and that Klebsiella pneumoniae liver abscess can occur in the United States and is not restricted to Taiwan.


This page was last updated on 06/13/03