Letter to the Editor
Meningitis after prostatic abscess due to hypervirulent Klebsiella pneumoniae
Meningitis tras absceso próstatico por Klebsiella pneumoniae hipervirulenta
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The usual clinical presentation is a liver abscess in the absence of underlying hepatobiliary disease. However, it can cause severe multi-system infections with haematogenous spread and can be fatal in healthy individuals.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The following is a case of hvKp infection in our environment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 72-year-old man with a medical history of dilated cardiomyopathy, severe pulmonary hypertension and a permanent bladder catheter due to benign prostatic hyperplasia who presented to the emergency department with a 48 -h history of decreased level of consciousness, pyuria, arterial hypotension and fever. He was admitted to Internal Medicine with a diagnosis of urinary sepsis, and treatment was started with ceftriaxone 2 g/24 h.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination he showed tachycardia (HR 145 bpm), tachypnoea (BR 40 cpm), coma (Glasgow Coma Scale 5 points) with nuchal rigidity and positive Kernig's sign. Blood test showed leukocytosis 18,300/mm<span class="elsevierStyleSup">3</span> with 90.4% polymorphonuclear and elevated C-reactive protein (CRP) (7.2 mg/dl) and 2600 leukocytes/uL, nitrite-positive urine sediment. A cranial CT scan was requested, showing images compatible with subacute infarction and leptomeningeal enhancement. Subsequently, a lumbar puncture was performed and cloudy cerebrospinal fluid with high outflow pressure was obtained. Laboratory results showed glucose <5 mg/dl, protein 1,101.4 mg/dl and leucocytes 48,773/mm<span class="elsevierStyleSup">3</span> (polymorphonuclear 76.9%). Gram-negative bacilli were isolated from 2 out of 2 peripheral blood cultures (BC).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was admitted to the Intensive Care Unit with a diagnosis of acute bacterial meningitis and gram-negative bacilli bacteraemia of the urinary tract. Treatment was started with meropenem 1 g/8 h, vancomycin 1 g/12 h and ampicillin 2 g/6 h, and a chest-abdomen-pelvis CT scan was performed, which revealed an abscess in the right prostate lobe (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and bilateral pulmonary infiltrates compatible with septic emboli. Surgical drainage was performed and a transthoracic echocardiogram was requested, which ruled out endocarditis. <span class="elsevierStyleItalic">Klebsiella pneumoniae (K. pneumoniae)</span> grew in all samples (BC, cerebrospinal fluid, bronchial aspirate and culture from drained prostatic abscess).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The patient showed clinical and laboratory improvement after drainage and was discharged from intensive care 72 h after admission, returning to the regular hospital ward. Antibiotic therapy was de-escalated to ceftriaxone 2 g/12 h according to antibiogram results and antibiotic treatment was completed for 21 days.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">K. pneumoniae</span> meningitis may originate in the meninges (primary) or may have a urinary, hepatic or post-craniotomy origin (following neurosurgery).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Batson noted in 1940 that the vertebral venous plexuses anastomose with the sacral, pelvic and prostatic venous plexuses, providing a direct communication system from the peritoneum and superior vena cava to the cranioencephalic venous system. This is the way tumours, infections and emboli spread.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the present case, Batson's plexus would explain the mechanism of infection by septic metastasis from a prostatic abscess to the lung, spinal canal and brain.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Strains of <span class="elsevierStyleItalic">hvKp</span> are common in haematogenous spread. Kp infections are usually multi-system. They affect the central nervous system, cause endophthalmitis and produce metastatic spread with a tendency to multi-organ abscess formation.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main pathogenesis of <span class="elsevierStyleItalic">hvKp</span> is due to the presence of virulence factors such as iron uptake systems, allantoin metabolism pathways, porins, efflux pump systems or kpc fimbriae. The hypermucoviscous phenotype is associated with the overproduction of a mucous capsule and the formation of biofilm, which allows the micro-organism to evade the host immune system.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, not all strains of <span class="elsevierStyleItalic">hvKp</span> are hypermucoviscous and this phenotypic feature has been described in cKp strains.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In recent decades, antimicrobial resistance has increased in hypervirulent strains, driven by the acquisition of genes that confer antibiotic resistance.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We therefore present a case of pulmonary and meningeal septic metastasis from a prostate abscess due to <span class="elsevierStyleItalic">hvKp</span>, which has been reported in very few cases in the literature to date. Early initiation of antibiotic therapy and surgical or percutaneous drainage of the focus of infection are essential to adequately treat the infection<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and prevent dissemination and emergence of antibiotic resistance.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This work has not been funded or subsidised in any way.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical considerations</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that the patient's written informed consent was obtained.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Ethical considerations" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 742 "Ancho" => 1000 "Tamanyo" => 75729 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prostatic abscess in right prostate lobe on axial chest-abdomen-pelvis CT scan.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hypervirulent Klebsiella pneumoniae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.A. 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