Abstract
Dear Editor:
K
Recently, a new species, Klebsiella varriicola, was recognized. Human infections with K varriicola are rare, and as of 17 January 2021, there have been no reports of biliary sepsis. We report emphysematous cholecystitis (EC) attributable to K varriicola in an immunocompetent elderly female that was managed by delayed interval laparoscopic cholecystectomy (LC) following an urgent percutaneous cholecystostomy (PC).
A 77-year old female with a history of hypertension and diabetes mellitus presented with right upper quadrant pain for four days. On examination, Murphy's sign was positive, suggestive of acute cholecystitis (AC). Liver function tests were normal. Abdominal computed tomography (CT) scanning revealed intraluminal gallbladder air, a thickened wall, and pericholecystic fat stranding, suggestive of EC. The common bile duct (CBD) was 12 mm, and a magnetic resonance cholangiopancreatography (MRCP) scan was done to rule out CBD stone. The scan confirmed EC with a distal CBD stone. Endoscopic retrograde cholangiopancreatography (ERCP) was performed, and a solitary pigment CBD stone was removed. Three blood cultures were negative, and antibiotic treatment was guided by a local antibiogram. The patient continued to have febrile episodes, so a PC was performed. Fluid culture revealed polymicrobial growth, and K variicola, Enterobacter aerogenes, and Enterobacter cloacae were isolated. The K variicola was sensitive to all antibiotics except amoxicillin. The E. aerogenes and E. cloacae were resistant to amoxicillin-clavulanic acid. Thus, we revised antibiotic therapy to ciprofloxacin for two weeks. The patient recovered, and interval LC was uncomplicated. Intra-operative fluid culture grew multi–drug-resistant K. pneumoniae. No further course of antibiotic was prescribed. Post-operative recovery was uncomplicated.
Klebsiella variicola is one of the seven K pneumoniae-related species and an emerging pathogen implicated in respiratory and urinary infections in elderly immunocompromised patients [3]. Until recently, K variicola had been misidentified as its more common counterpart K. pneumoniae [4]. It commonly is isolated from banana trees and sugarcane, and thus K variicola infections are considered examples of phytosis. A PubMed search on 17 January 2021 revealed no cases of AC attributable to K variicola.
Now, AC is a common surgical emergency classically treated with antibiotics guided by a local antibiogram as well as by early cholecystectomy [5]. Emphysematous cholecystitis is a rare form of AC that is associated with worse outcomes, especially if sepsis is not treated in timely fashion. In EC patients with known CBD stones, prompt ERCP is warranted to achieve biliary decompression to treat possible concomitant cholangitis. Our patient remained febrile even after CBD clearance, and the case review was undecided about the need of emergency LC. Thus, an option of PC was discussed, and her physiology was restored after PC. As hypervirulent K pneumoniae as well as Enterobacter spp. are associated with gas formation, we remain uncertain if the gas formation in our patient was a product of K variicola. The resistance pattern of K variicola isolates is unknown; in our patient, the only resistance was to ampicillin.
In conclusion, we report the first case of EC caused by K. variicola. As K variicola is an emerging pathogen, clinicians have a duty to report these cases.