A 69-year-old woman consulted a hospital with a chief complaint of 7 days of fever, 4 days of blurry vision, and 4 h of glossolalia. She had a history of untreated diabetes mellitus and tuberculosis, which was cured 50 years ago. She had no other medical history and was not an alcohol drinker or a smoker. On admission, her initial vital signs included a body temperature of 38.2  C, a heart rate of 118 beats/min, a blood pressure of 128/60 mmHg, a respiratory rate of 20 breaths/min, and oxygen saturation of 98%. She was experiencing clouding of consciousness and was not able to cooperate with physical examination. After opening her eyelid, a mild conjunctival and corneal edema was found. Massive fibrinous exudation showed at the margin of the pupil with no pupillary light reflex in the right eye. There was percussion pain in the hepatic region and tenderness in the right upper quadrant of the abdomen. There was no hepatosplenomegaly. Meningeal irritation signs were suspected to be positive.
Laboratory test results revealed a white blood cell count of 17.5 x 109/L, with a neutrophil predominance of 89.8%, and a platelet count of 128 x 109/L. The concentration of C-reactive protein (CRP) was 204.87 mg/L, and the procalcitonin (PCT) level was 14.82 ng/L. Arterial blood gas results were as follows (on 6 L/min oxygen via nasal cannula): a pH of 7.40, PaCO2 of 15 mmHg, PaO2 of 96 mmHg, HCO3 of 9.4 mmol/L, and lactic acid of 1.9 mmol/L. The coagulation profile showed an international normalized ratio of 1.47, an activated partial thromboplastin time of 38.9 s, and a prothrombin time of 14.9 s. Liver function test results were as follows: aspartate aminotransferase of 33.8 U/L; alanine aminotransferase of 33 U/L; lactate dehydrogenase of 303.86 IU/L; total bilirubin of 10.55 micromol/L; and direct bilirubin of 6.04 micromol/L. The fasting blood sugar level was 14.5 mmol/L, and HbA1C was 13.3%. A urine full report showed proteinuria (++) with 1.3 pus cells per high power field. Creatinine was 87 micromol/L, and urea was 8 mmol/L. Peripheral blood cultures were collected twice.
Further imaging examinations were performed. An ultrasound scan (US) revealed a mixed echogenic mass containing solid and cystic components in the right lobe of her liver, measuring 5.0 x 3.9 cm in size. An abdominal CT scan showed a single low-density focus in the right lobe of the liver (45 mm x 38 mm), which demonstrated a possible liver abscess (Figure 1). No other intra-abdominal pathologies such as gallstones were observed on these imaging examinations. In order to detect intraocular diseases, an ocular ultrasound was performed. It revealed lens clouding in both eyes and vitreous clouding in both eyes (excluding blood or pus accumulation in the vitreous of the right eye), excluding partial retinal detachment in the right eye. Because of her 4-h delirium before admission, meningitis was considered. A head CT scan and a lumbar puncture were necessary. However, there were no remarkable findings according to the head CT result. Puncture examination showed that the intracranial pressure was 150 mm H2O. The cerebrospinal fluid (CSF) appeared yellow and purulent (Figure 2), revealing a 580,000 x 106/microL white blood cell count with a multinucleated cells percentage of 98%, protein above 15 g/L, and glucose less than 1.1 mmol/L. The CSF was also submitted for Gram staining and bacterial culture.
The patient was preliminarily diagnosed with a primary liver abscess, endogenous endophthalmitis, and meningitis. Ultrasound-guided percutaneous catheter drainage (PCD) of the liver abscess was immediately performed, with a continuous drainage of 110-ml yellow pus. Specimens were retained for culture. Meropenem was given intravenously as an empirical treatment. The patient was given 0.1 ml of vancomycin (10 g/L) and 0.1 ml of ceftazidime (20 g/L) were by intravitreal injection. On the third day after admission, the oxygenation index reduced to 180, and the self-cleaning ability of the airway was poor. A tracheotomy was performed, and mechanical ventilation was started at once. Both blood and drainage fluid cultures grew K. pneumoniae with a high mucosal phenotype, which was sensitive to all the tested antibiotics. A string test showed a positive result (string >=5 mm). The cerebrospinal fluid culture showed gram-negative bacteria. With the completion of the assays, the ocular disease was diagnosed as endophthalmitis complicated by a liver abscess caused by hypervirulent K. pneumoniae. Ceftazidime was used alone for intravitreal injection.
In conclusion, the patient had a liver abscess as the primary focus of infection with migratory infection of the eye and meninges. The pathogen was considered to be hypervirulent K. pneumoniae (hvKP) according to the results of the drug sensitivity test, clinical manifestations, and the string test (+). The patient was finally diagnosed with a K. pneumoniae liver abscess, purulent meningitis, and endogenous K. pneumoniae endophthalmitis in the right eye. Meropenem was continued to control the bloodstream infection. After 15 days of treatment, her body temperature became normal, and the rechecked blood routine, CRP, and PCT had normalized. A lumbar puncture and an abdominal CT were performed as part of reexamination. The CSF appeared transparent (Figure 2), revealing a 34 x 106/microl white blood cell count with a multinucleated cells percentage of 5%, protein of 3 g/L, and glucose of 6.1 mmol/L. CT showed a low-density shadow (15 mm x 21 mm) that was much smaller than the earlier one in the right lobe of her liver. She was successfully weaned from the ventilator with an oxygenation index of beyond 300 and was catheterized with oxygen at the tracheotomy site. She opened her eyes spontaneously but was not able to cooperate with the physical examination. Therefore, the eyesight of her right eye could not be evaluated. She had stable vital signs with a heart rate of 94 beats/min, blood pressure of 132/75 mmHg, and oxygen saturation of 100%. The anti-infective therapy was changed from meropenem to ceftazidime and lasted for 2 weeks. The patient was discharged with an improved condition and was followed up for long-term outcomes. However, during follow-up, she developed complications due to severe pneumonia and eventually died in a local hospital.