Diagnosis at first sight
Multiple invasive abscesses syndrome in immunocompetent patient
Síndrome de abscesos múltiples invasivos en paciente inmunocompetente
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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "Jorge Alberto" "apellidos" => "Cortés" "email" => array:1 [ 0 => "jacortesl@unal.edu.co" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Medicina Interna, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Infectología, Hospital Universitario Nacional de Colombia, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de abscesos múltiples invasivos en paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 90324 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Palpebral oedema, eyelid erythema, proptosis, 360° chemosis, with abundant purulent discharge.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">This was a 28-year-old male with no hospital medical history or use of antibiotics in the last six months who came to the Accident and Emergency Department (A&E) with a three-day history of fever, chills, asthenia, reduced appetite and myalgia. He was treated with diclofenac <span class="elsevierStyleSmallCaps">im</span>, injected into his left gluteal muscle. During the following days, his symptoms persisted, associated with oedema, erythema, heat and redness at the application site. Concomitantly, he developed periocular oedema and erythema, eye pain and decreased visual acuity, for which he returned to A&E.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On arrival he was feverish and tachycardic, with local inflammatory signs in his left gluteal region. Ophthalmology examination revealed palpebral oedema, eyelid erythema, ophthalmoplegia, proptosis, 360° chemosis, purulent discharge in the cul-de-sac, 2-mm, hyporeactive pupil, with pain triggered by eye movements. It was not possible to see the fundus of the eye (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Contrast magnetic resonance imaging of the skull with emphasis on orbits revealed rupture of the eyeball towards the superior aspect, purulent material in the anterior and posterior chambers, myositis of the extrinsic muscles of the eye, and preseptal and palpebral inflammation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Contrast tomography of the abdomen showed hepatomegaly, multiple bilateral cystic images predominantly in the right interpolar region 42<span class="elsevierStyleHsp" style=""></span>mm in size, compatible with liver abscess in the right lobe (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Chest tomography revealed lung nodules in the right upper, middle and lower lobes, some of them cavitary (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Outcome</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was started on antibiotics with ceftriaxone 2<span class="elsevierStyleHsp" style=""></span>g <span class="elsevierStyleSmallCaps">iv</span>/12<span class="elsevierStyleHsp" style=""></span>h and vancomycin 1<span class="elsevierStyleHsp" style=""></span>g <span class="elsevierStyleSmallCaps">iv</span>/12<span class="elsevierStyleHsp" style=""></span>h. Blood cultures were positive for <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> with the usual sensitivity pattern. Antibiotic therapy was continued with ceftriaxone alone. In the light of these findings, enucleation of the left eyeball was performed without complications. An extension study of the supratentorial brain parenchyma showed multiple hyperintense lesions in T2 and FLAIR, with peripheral ring enhancement and central diffusion restriction, less than a centimetre, compatible with small abscesses of probable embolic origin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Repeat blood cultures taken 48<span class="elsevierStyleHsp" style=""></span>h after antibiotic therapy were negative. Transoesophageal echocardiogram showed no signs of vegetations. A collection of 154 cm<span class="elsevierStyleSup">3</span> was documented in soft tissues in the patient's left gluteal region, with disruption of the superficial fascia, myositis in the musculature of the gluteal compartment and oedema of the deep fascia. He was taken to theatre for surgical lavage on two separate occasions, with Gram staining and cultures of secretions negative. The final diagnosis was multiple abscesses due to hypervirulent <span class="elsevierStyleItalic">K. pneumoniae.</span></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span> is a member of the Enterobacteriaceae family of bacteria. It is highly important from a clinical point of view and is responsible for both hospital- and community-acquired infections. Most infections caused by this pathogen are associated with pneumonia or urinary tract or intra-abdominal infections. However, in the mid-1980s, a different clinical syndrome emerged, associated with hypervirulent subtypes of the bacteria and characterised by bacteraemia, liver abscesses and serious disseminated infections. Although initially described in Southeast Asia, since its recognition, cases have been reported worldwide.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In the case we present here, the patient denies travel to Southeast Asia or frequenting restaurants associated with that region.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Capsular serotypes K1 and K2 are considered the most virulent strains of <span class="elsevierStyleItalic">K. pneumoniae</span>, with K1 the strain most commonly found in patients with invasive liver abscess syndrome. The hypermucosity phenotype has been cited as an important virulence factor of this pathogen.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> This is characterised by increased production of capsular polysaccharides, which aids bacterial evasion of phagocytosis by macrophages and mononuclear cells. At the molecular level, specific virulence genes have been described, such as rmpA (responsible for regulating the mucoid phenotype) and magA (responsible for the capsular serotype K1), both of which are determining factors of hypervirulence.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Diabetes mellitus has been identified as the most common risk factor.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> The infection can compromise a number of different organs and can cause meningitis or brain abscesses, endogenous endophthalmitis, lung, prostate and soft tissue abscesses, necrotising fasciitis and osteomyelitis, as in the case presented here.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> Early percutaneous drainage of the liver abscess and targeted antibiotic treatment are the most important predictors in relation to decreasing mortality risk and a lower risk of complications.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Outcome" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Comments" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Díaz-Brochero C, Gerena LG, Cortés JA. Síndrome de abscesos múltiples invasivos en paciente inmunocompetente. Enferm Infecc Microbiol Clin. 2020;38:500–502.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 680 "Ancho" => 905 "Tamanyo" => 90324 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Palpebral oedema, eyelid erythema, proptosis, 360° chemosis, with abundant purulent discharge.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 679 "Ancho" => 1255 "Tamanyo" => 98901 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) FLAIR images showing purulent material in the anterior and posterior chambers accompanied by supraorbital laminar collection oedema, intra- and extraconal soft tissue oedema, and myositis of the extrinsic muscles of the eye. B) Rounded hyperintense lesions in FLAIR, with peripheral ring enhancement and central diffusion restriction of less than a centimetre, with a tendency to confluence in the left medial frontal gyrus, compatible with small abscesses.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1383 "Ancho" => 1505 "Tamanyo" => 274734 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A) Liver increased in size (25<span class="elsevierStyleHsp" style=""></span>cm) with normal contours and shape, with a multiloculated hypodense image with well-defined borders measuring 165<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>118<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>105<span class="elsevierStyleHsp" style=""></span>mm. B) Lung nodules in the right upper, middle and lower lobes, some of them cavitary.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive Klebsiella pneumoniae Syndrome in North America" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.A. Nadasy" 1 => "R. Domiatisaad" 2 => "M.A. Tribble" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin. Infect. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 9 | 2 | 11 |
| 2024 September | 15 | 3 | 18 |
| 2024 August | 16 | 2 | 18 |
| 2024 July | 14 | 3 | 17 |
| 2024 June | 13 | 2 | 15 |
| 2024 May | 12 | 5 | 17 |
| 2024 April | 16 | 4 | 20 |
| 2024 March | 12 | 2 | 14 |
| 2024 February | 18 | 7 | 25 |
| 2024 January | 11 | 1 | 12 |
| 2023 December | 12 | 0 | 12 |
| 2023 November | 13 | 1 | 14 |
| 2023 October | 23 | 5 | 28 |
| 2023 September | 9 | 0 | 9 |
| 2023 August | 12 | 0 | 12 |
| 2023 July | 11 | 3 | 14 |
| 2023 June | 12 | 5 | 17 |
| 2023 May | 36 | 3 | 39 |
| 2023 April | 52 | 1 | 53 |
| 2023 March | 34 | 2 | 36 |
| 2023 February | 22 | 5 | 27 |
| 2023 January | 12 | 4 | 16 |
| 2022 December | 23 | 4 | 27 |
| 2022 November | 19 | 5 | 24 |
| 2022 October | 11 | 7 | 18 |
| 2022 September | 16 | 9 | 25 |
| 2022 August | 12 | 6 | 18 |
| 2022 July | 10 | 7 | 17 |
| 2022 June | 11 | 9 | 20 |
| 2022 May | 8 | 7 | 15 |
| 2022 April | 13 | 10 | 23 |
| 2022 March | 10 | 10 | 20 |
| 2022 February | 6 | 4 | 10 |
| 2022 January | 12 | 7 | 19 |
| 2021 December | 21 | 9 | 30 |
| 2021 November | 20 | 10 | 30 |
| 2021 October | 26 | 17 | 43 |
| 2021 September | 28 | 6 | 34 |
| 2021 August | 14 | 4 | 18 |
| 2021 July | 8 | 4 | 12 |
| 2021 June | 10 | 4 | 14 |
| 2021 May | 4 | 0 | 4 |
| 2021 January | 6 | 0 | 6 |
| 2020 December | 3 | 2 | 5 |
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