Thrombosis,Septic Emboli,and Multiple Abscesses Triggered by Klebsiella pneumoniae : A Case Report and Review of Literature

Introduction

Klebsiella pneumoniae is a leading cause of gram-negative infections. ¹ Despite being a normal part of colonic flora, it is pathogenic when found in the bladder and lung. ² Klebsiella infection is strongly associated with uncontrolled diabetes. Also, Klebsiella pneumoniae may trigger pyogenic liver abscess, perinephric abscess, renal vein thrombosis, thrombophlebitis, septic pulmonary emboli, Lemierre syndrome, and meningitis. Although infection-associated thrombosis is well documented in literature, few studies have been published on the occurrence of bilateral renal vein thrombosis and inferior vena cava (IVC) thrombosis along with septic pulmonary emboli triggered by Klebsiella pneumoniae in the same patient.^3,4 The following case suggests one such example.

Case Presentation

A 58-year-old woman with a past medical history of uncontrolled diabetes mellitus and Klebsiella lung abscess came to the emergency room (ER) with complaints of ongoing abdominal pain, nausea, and vomiting for 5 days. Patient also reported swelling of the left third finger and the left calf. Physical examination was significant for left third finger swelling and left calf swelling. Vitals showed low-grade fever and elevated heart rate. Lab results were significant for leukocytosis and high blood glucose (see Table). Abdominal ultrasound result showed left renal lesion measuring 2.2 cm. Computed tomography (CT) of abdomen and pelvis revealed bilateral renal vein and IVC thrombosis along with perinephric abscess (Figure 1). The CT chest result revealed innumerable bilateral nodular and mass-like opacities that represent septic emboli (Figure 2). Furthermore, X-ray of the third left finger showed soft-tissue swelling and abscess. Left calf ultrasound (US) revealed nonfluctuant collection measuring 4.2 cm that represents an abscess. Transthoracic echocardiogram did not show any vegetation on the valves. Patient was treated with appropriate antibiotics and Lovenox. Blood culture was positive for Klebsiella. The US- and CT-guided aspiration of the perinephric abscess along with incision and drainage of the left third finger abscess were completed during hospital stay. Again, left third finger abscess culture showed Klebsiella. String test was not done. Antibiotics were de-escalated to Rocephin based on sensitivities. Patient was discharged and asked to complete the course of intravenous (IV) Rocephin for additional 3 weeks.

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Table.

Initial laboratory results with respective reference ranges.

Laboratory parameters	On admission	Reference range
White blood cells*	21.5	4.8-10.8 × 103/μL
Hemoglobin	10.8	13.7-17.5 g/dL
Hematocrit	31.6	38.8%-50%
Platelets	583	150-450 × 103/μL
Sodium	128	136-145 mmol/L
Potassium	3.9	3.5-5.3 mmol/L
CO2	18	20-31 mmol/L
Blood urea nitrogen	27	6-24 mg/dL
Creatinine	0.7	0.6-1.2 mg/dL
Random blood glucose*	318	70-140 mg/dL
Anion gap	19	6-19 mmol/L
Procalcitonin*	0.92	<0.05 ng/mL
Nitrite*	Positive	Negative

*

Significant laboratory results.

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Figure 1.

Computed tomography of the abdomen and pelvis showing perinephric abscess in the left kidney.

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Figure 2.

Computed tomography of the chest showed bilateral septic emboli in the lung.

Discussion

Previously documented studies have shown some relationship between nephrotic syndrome and renal vein thrombosis.^5,6 Also, multiple reports have noted the occurrence of thrombosis during infectious process. However, in contrast with thrombosis in other contexts, inflammation triggered by pathogen is the cause of thrombosis during infection. ⁷ The severity of infection and extent of subsequent inflammation determine the level of thrombosis that may occur. ⁷ Thrombosis triggered by inflammation is common in gram-negative septicemia. This is because lipopolysaccharides released in gram-negative infection can modify the endothelial lining of blood vessels to promote thrombosis. ⁸ Although many studies have linked the improvement of thrombosis with the resolution of abscess and infection focus, treatment with combination of antibiotics and anticoagulation is common and well tolerated. The patient under review had Klebsiella pneumoniae bacteremia that triggered septic emboli, renal vein thrombosis, IVC thrombosis, and diffuse swelling. Apart from the drainage of abscess, she received aggressive antibiotics and anticoagulation. Subsequent clinical improvement was evident.

Septic pulmonary embolism (SPE) is a well-documented complication of Klebsiella pneumoniae. The SPE occurs when septic emboli enter the pulmonary circulation. ⁹ Patients may present with cough, chest pain, shortness of breath, and tachycardia. ¹⁰ This patient had septic emboli on presentation with minimal respiratory symptoms. Her symptoms were completely resolved after receiving antibiotics and anticoagulation. At times, aggressive antibiotics and other supportive measures may be sufficient in managing septic pulmonary embolism in patients with minimal respiratory symptoms. Riangwiwat and Dworkin reported SPE and multiple abscesses in an IV drug user who was diagnosed with tricuspid valve infective endocarditis triggered by Klebsiella pneumoniae infection. ¹¹ The patient was treated with combined 6-week Rocephin and 2-week Gentamicin along with early tricuspid valve repair.

Klebsiella pneumoniae can also trigger regional vein thrombosis and liver abscess. Thrombophlebitis of hepatic and portal veins does occur in patients diagnosed with Klebsiella liver abscess (KLA). Reports have shown that Klebsiella pneumoniae is responsible for many cases of liver abscess in China, particularly in diabetic patients without any documented history of biliary disease.^12,13 Untreated KLA may trigger the spread of infection to other parts of the body. ¹⁴ In most cases, drainage of abscess is pivotal to the resolution of infection and thrombosis. In a retrospective study conducted by Molton et al, ¹⁵ recanalization of affected veins in thrombophlebitis associated with KLA was seen after abscess drainage. Most participants in this study responded positively to abscess removal and antibiotics without the use of any anticoagulation.

Cerebral venous sinus thrombosis (CVST) has been documented in Klebsiella infection. The CVST is a serious cerebrovascular disease most likely seen in young adults and children. ¹⁶ This disease can be triggered by various hypercoagulable states, infection, inflammatory diseases, and head injury. ¹⁷ Zhou et al ¹⁸ reported on a 54-year-old man who initially had fever and altered mental status on presentation. Brain magnetic resonance imaging (MRI) and magnetic resonance venography revealed thrombosis in the transverse and sigmoid sinuses. Also, abdominal CT and liver MRI showed multiple liver abscesses. Blood culture grew Klebsiella pneumoniae. Patient was diagnosed with sepsis secondary to Klebsiella infection, KLA, and CVST. Symptoms resolved with aggressive antibiotic regimen and Lovenox.

Infection in the oropharynx and thrombosis of the internal jugular vein are some of the pathologies seen in Lemierre syndrome. Although this infection is commonly caused by Fusobacterium necrophorum, Lemierre syndrome triggered by Klebsiella pneumoniae has been reported in literature. For instance, Tsai et al ¹⁹ reported on a 45-year-old woman who came into the ER with complaints of fever, difficulty swallowing, painful swallowing, cough, and swollen neck. CT head and neck showed abscess formation in the left-sided neck area, thrombosis in the left internal jugular vein, and lymphadenopathy. Blood cultures grew Klebsiella pneumoniae. Patient improved with aggressive antibiotics and anticoagulation.

Occurrence of intracardiac thrombus has been documented in community-acquired Klebsiella pneumoniae infection. Kumar et al ²⁰ reported on a 55-year-old woman who came to the ER with complaints of fever and dyspnea. Blood cultures were remarkable for Klebsiella pneumoniae. Echocardiogram result was significant for mild systolic dysfunction and two large intraventricular masses suggestive of thrombi. Intraventricular thrombi and lung consolidation resolved with antibiotics and anticoagulation.

Klebsiella pneumoniae when compared with other bacteria is more likely to cause thrombosis in different areas of the human body. Therefore, in addition to source control, the use of anticoagulation may be beneficial in most patients to prevent undesirable complications. Although there is currently no consensus in literature on the use of anticoagulation in thrombosis caused by Klebsiella pneumoniae, a multimodal approach to management involving the use of culture-directed antibiotics, drainage of abscess, and anticoagulation has been proposed. ²¹ And regardless of the response of patients to combination of abscess drainage and antibiotics without the use of anticoagulation in some instances, a study showed that anticoagulation use was helpful in patients with portal vein thrombosis triggered by Klebsiella infection. ²² Given this mixed picture in literature, the use of anticoagulation in addition to prompt abscess drainage alongside antibiotics is beneficial in most patients if there are no contraindications.

Conclusion

Thrombosis, a serious complication of Klebsiella infection, can trigger diverse pathologies highlighted above. It is important to quickly identify this infection and treat it aggressively. Studies have revealed that most patients often respond to a combination of antibiotics, abscess drainage, and anticoagulation. Since Klebsiella infection occurs frequently in diabetic patients, adequate control of blood glucose can further help to limit the complications associated with this disease.