Loading

Archives of Emergency Medicine and Critical Care

Multiple Brain Abscess in a Patient with Community - Acquired Klebsiella Pneumoniae Invasive Syndrome

Case Report | Open Access | Volume 7 | Issue 2

  • 1. Department of Neurology, Hospital Sirio-Libanés de Buenos Aires, Argentina
+ Show More - Show Less
Corresponding Authors
Raul O. Domínguez, Doctor en Medicina. Profesor Consulto de Neurología Universidad de Buenos Aires. Neurology Department, Hospital Sirio-Libanés de Buenos Aires, Argentina, Tel: 5491144064574
Abstract

Multiple brain abscesses is a life threatening condition, which challenges physicians clinical skills. We present a 65 years old man with a medical history of Type 2 Diabetes presented to ED with a history of 2 days of confusion and chest pain. The patient remained stable for a few days. After that he developed fever and his neurological status began to worsen. Abdomen CT revealed a liver abscess. CSF analysis matched for meningitis, brain MRI showed multiple focal images with a bilateral, supra and infratentorial distribution and restrictive intra-ventricular content interpreted as pyoventriculitis. Despite the thorough treatment with broad range antibiotics and drainage of the liver abscess, generalized infection persisted, leading to a septic shock and eventually his decease. Klebsiella Pneumoniae is a well known human pathogen. Extra-hepatic complications resulting from bacteraemic dissemination, including endophthalmitis, meningitis, necrotising fasciitis, and other illnesses, have also been recorded. K pneumoniae is known for being involved in Healthcare-Acquired infections but in the past few years it has become a source of acquired-community infections leading to a broad variety and eventually severe clinical presentation.

Keywords

• Multiple Brain Abscess

• Klebsiella Pneumoniae

• Type 2 Diabetes

• Acquired-community infections

CITATION

Domínguez RO, Howard JA (2023) Multiple Brain Abscess in a Patient with Community - Acquired Klebsiella Pneumoniae Invasive Syndrome. Arch Emerg Med Crit Care 7(2): 1059.

INTRODUCTION

Bacteria responsible for brain abscesses can be aerobic (most frequently Staphylococcus, Streptococcus and Pneumococcus) and anaerobic. Klebsiella pneumoniae usually causes urinary tract infections, pneumonia, and other infections in hospitalized persons whose immunity is compromised. Researchers have noted a distinctive syndrome of community-acquired pyogenic liver abscess that is complicated by metastatic infections [1].

Diabetes mellitus (DM) seems to be a risk factor for the liver abscess and it is associated with poor visual outcome in patients with endophthalmitis. Glycaemic control might prevent the development of metastatic complications caused by Klebsiella pneumoniae serotypes K1 and K2. In the United States, 53.6 years was the mean age of presentation. Men represented 68% of the cases. The most ethnic origin affected was de Asian, followed by Hispanic, Blacks and Whites. It seems that the ethnic origin of patients is important but the reasons for the predominance of liver abscess in Asian people are unclear. The main underlying disorder is DM (29%), followed by Hepatobiliary diseases. Main metastatic infection is targeted to the lung (16%), eye (11%) and CNS (8%) [2].

Brain abscess is a localized infection of the CNS. It is formed by a central necrotic area surrounded by an external wall (collagen, granulation tissue, macrophages, gliosis). It accounts for 1-2% of brain occupying space lesions in western countries and 8% in developing countries. They are frequent in adults while in only 15-30% of the cases, they involve patients younger than 15 years old [3]. The commonly identified predisposing risk are underlying disease such as infection with the Human Immunodeficiency Virus (HIV), a history of treatment with immunosuppressive drugs, disruption of the natural protective barriers surrounding the brain (eg, due to surgery, trauma, mastoiditis, sinusitis, or dental infection), or a systemic source of infection (eg, endocarditis or bacteremia). Additionally, congenital heart disease, meningitis, and certain procedures such as esophageal dilatation are also associated with multiple abscesses in brain parenchyma [4].

Bacteria enter the liver from the enterohepatic circulation and cause liver abscesses, then access the pulmonary circulatory system and invade remote sites [5]. The most common localization of a pyogenic abscess in the brain is the supratentorial region, in the subcortical white matter, especially, if they come from hematogeneous spread of a distant infection. Abscesses secondary to middle ear otitis are typically located in the temporal lobe or in the cerebellum. Evolution to brain abscess consists in the following stages:

- Early cerebritis (from the 1st to the 3rd day), characterized by an inflammatory response with predominance of polymorphonuclear leukocytes.

- Late cerebritis (from the 4th to the 9th day). The immune response is mediated by lymphocytes and macrophages; central necrosis formation starts with peripheral neoangiogenesis and presence of fibroblasts; the neo formed vessels have no blood-brain barrier

.- Early encapsulation (from the 10th to the 13th day), in which there is formation of surrounding peripheral wall with central necrosis.

- Late capsule stage (from the 14th day), characterized by a mature encapsulate brain abscess with a wide central necrotic area.

MRI shows pyogenic abscess as a round or oval-shaped mass with a central area of suppurative necrosis and a peripheral capsule. The central necrotic area is hypointense to the cerebral white matter on T1-weighted and hyperintense on T2-weighted images. These features are not always present. The external capsule appears as a complete hypointense on T2- weighted and hyperintense on T1- weighted images rim. The short T1 and T2 of the rim seem to be due respectively to the presence of collagen fibres and to macrophages releasing free radicals with a paramagnetic effect. The surrounding vasogenic oedema appears hypointense on T1-weighted and hyperintense on T2-weighted images [3].

CASE

A 65 years old man, with a medical history of Type 2 Diabetes treated with Metformin presented to our Emergency Department with a history of 2 days of confusion and complained of chest pain. On arrival, patient’s Blood Pressure was 100/60 mmHg, PR: 80/min, RR: 20/min, SpO2: 95%, T°: 36° Celsius. He was confused and bradypsychic. Physical examination showed mucosal dryness and right periorbital cellulitis. The patient was fully awake and no neurological deficit was detected.

Chest X- ray was normal. Arrival laboratory showed WBC: 10960/mm3 (Neutrophils: 90%), slightly lowered Sodium and Potassium, Creatinine: 1.2 mg/dL, BUN: 72 mg/dL, Blood glucose: 266 mg/dL. Total bilirubin: 2.8 mg/dL (Direct bilirubin: 79%), Alkaline phosphatase: 298 UI/L. Ampicilin/Sulbactam had been administered due to the previously mentioned periorbital infection and the presence of Leukocytes in urine which suggested urinary tract infection.

After three days from his arrival, there was a rise of his body temperature to 38.7°C, high airways secretion, a rise in WBC, platelet count to 46000/mm3 and radiographic evidence of pneumonia, reason why Clarithromycin was added to the previously installed treatment. At this point, the patient remained clinically stable and no decrease in his consciousness level was noticed.

One week after his hospitalization, despite treatment and even though laboratory tests tended to improve, the patient turned drowsy. Acid-Base state analysis shows respiratory acidosis and metabolic alkalosis. New laboratory and images tests were performed. Treatment was changed to Piperacillin/ Tazobactam and Vancomycin.

Chest CT scan showed alveolar infiltrate in Upper right lobe and interstitial in the Upper left lobe. There was also scarce bilateral pleural effusion. Abdominal CT scan with contrast showed a 74 x 75 mm size abscess in de V segment of the liver, (Figure 1). Metronidazol is added to treatment. Brain CT scan showed no abnormalities.

Contrasted abdominal CT scan. V liver segment abscess.

Figure 1: Contrasted abdominal CT scan. V liver segment abscess.

Non contrast Brain MRI revealed multiple focal images with enhanced signal in FLAIR and a cortical/subcortical, bi hemispherical and supra and infratentorial. Some of them presented restriction in DWI. Restrictive intra-ventricular content is also observed in slope areas (pyoventriculitis) and periventricular hyper-intensity in T2/FLAIR predominant in occipital extensions (Figure 2 [A, B, C]).

A and B: Brain MRI. Transverse plane T2- weighted and FLAIR showing multiple focal with enhanced signal images, bilateral, supra and infratentorial  distribution. C:  Brain MRI.  Multiple focal images with restriction in DWI. Restrictive intra-ventricular fluid observed in slope areas (pyoventriculitis).

Figure 2 A and B: Brain MRI. Transverse plane T2- weighted and FLAIR showing multiple focal with enhanced signal images, bilateral, supra and infratentorial distribution. C: Brain MRI. Multiple focal images with restriction in DWI. Restrictive intra-ventricular fluid observed in slope areas (pyoventriculitis).

CSF analysis showed: White cells 212 /mm3, Mon: 91%, PMN: 9%, Red cells: Isolated, Glucose: 24 mg/dL, Proteins: 4.88 g/L, pH: 7.77, Lactic acid: 10.1 mmol/L, Appearance: Yellow, clear.

Anti HSV 1 IgG: Positive 1/320, Anti HSV 1 IgM: Negative, Anti HSV 2 IgG: positive 1/160, Anti HSV 2 IgM: Negative, Anti CMV IgG: 1203 U/mL.

Urine culture: Klebsiella Pneumoniae

Blood cultures Shows Klebsiella Pneumoniae Resistant to Ampicilin.

Ocular culture Results: #1 Candida Glabrata, #2 Klebsiella Pneumoniae

CSF Culture showed No germs growth. It’s remarkable that the patient was already on antibiotic treatment at the time of the lumbar puncture because of the urinary tract infection and the liver abscess.

Echocardiogram: Concentric hypertrophy, mild enlargement of the left atrium, Diastolic dysfunction I, pulmonary hypertension.

Liver abscess percutaneous puncture and culture is performed, awaiting for results at the time this article is being written.

The patient is transferred to Intensive Care Unit due to the severity of his condition, received Oro-tracheal intubation and vasopressor drugs where he worsens and he eventually deceases.

DISCUSSION

Multiple brain abscesses is a life threatening condition, which challenges physicians clinical skills. We present a patient that arrived to the ED of our Hospital with confusion and bradypsychia, whose evolution progressively worsened and finally deceased due to septic shock despite treatment with broad spectrum antibiotics and drainage of the liver abscess. Different laboratories and imaging techniques were performed, finding a liver abscess, a bilateral lung infection, endophthalmitis and multiple focal brain abscesses and pyoventriculitis. Ocular secretion, Urine and Blood cultures showed infection by Klebsiella pneumoniae. No right to left shunt was found, but only transthoracic echocardiogram had been performed due to the clinical and hemodynamic instability of the patient.

K. pneumoniae is known for being involved in nosocomial infections. In the United States, Europe, Argentina, and Australia it has been observed that hospital-acquired K. pneumoniae infections predominate, with community-acquired bacteremia being caused by urinary tract infection, vascular catheter infection, and cholangitis. Classic community-acquired pneumonia is no longer an important entity in these regions. In South Africa, pneumonia (especially in alcoholics) continues to be an important community-acquired infection. In Taiwan distinctive infections such as liver abscess, endophthalmitis, and meningitis have emerged as an important public health issue [6].

CONCLUSIONS

Klebsiella pneumoniae infections are usually seen as Hospital- acquired. When it comes to liver abscess in immunocompromised patients it’s necessary to take account of K. pneumoniae and the possibility of a Community-acquired illness. Multiple brain abscesses in the context of a K. pneumoniae invasive syndrome is a severe clinical condition which may lead to patient’s death. Therefore, it is imperative to suspect of this presentation when the early stage of the disease sprouts.

Domínguez RO, Howard JA (2023) Multiple Brain Abscess in a Patient with Community - Acquired Klebsiella Pneumoniae Invasive Syndrome. Arch Emerg Med Crit Care 7(2): 1059.

Received : 27 Oct 2023
Accepted : 27 Nov 2023
Published : 30 Nov 2023
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X