1/#IDMedEdCase by Drs. Hayon & @Bacteri_Al
50YOM w/ uncontrolled T2DM p/w RUQ pain x 2d and unintentional weight loss x 3m.
T 101F, HR 123, RUQ TTP w/o peritoneal signs, abd non-distended
WBC 18 (93% PMNs), Hb 8.9, ALP >700, ALT 60, Tbili wnl, Alb 2.7
CT A/P shows:
50YOM w/ uncontrolled T2DM p/w RUQ pain x 2d and unintentional weight loss x 3m.
T 101F, HR 123, RUQ TTP w/o peritoneal signs, abd non-distended
WBC 18 (93% PMNs), Hb 8.9, ALP >700, ALT 60, Tbili wnl, Alb 2.7
CT A/P shows:
2/CT most suggestive of pyogenic liver abscesses.
What percentage of patients will also have positive blood cultures?
What percentage of patients will also have positive blood cultures?
3/~50% have positive blood cultures 😱
On micro rounds you see the following....
dx.doi.org/10.4161%2Fviru…
On micro rounds you see the following....
dx.doi.org/10.4161%2Fviru…
4/What is the causative organism?
5/Answer:
K. pneumoniae with (+) string test, indicative of a hypermucoviscous strain (more on this later)
Let's briefly review pyogenic liver abscesses.
K. pneumoniae with (+) string test, indicative of a hypermucoviscous strain (more on this later)
Let's briefly review pyogenic liver abscesses.
6/These host factors ⬆️risk for pyogenic liver abscesses:
🔸Diabetes mellitus
🔸Older age (peak incidence 5th and 6th decades)
🔸Malignancy
🔸Cirrhosis
🔸Other immunocompromising condition
🔸Diabetes mellitus
🔸Older age (peak incidence 5th and 6th decades)
🔸Malignancy
🔸Cirrhosis
🔸Other immunocompromising condition
7/Most commonly involve the right hepatic lobe (>60%)
There are 5 main routes of infection:
🔸Biliary tree (most common)
🔸Portal vein
🔸Hepatic artery
🔸Direct extension
🔸Penetrating trauma
There are 5 main routes of infection:
🔸Biliary tree (most common)
🔸Portal vein
🔸Hepatic artery
🔸Direct extension
🔸Penetrating trauma
8/Most common presenting sx ➡️fever, abd pain, nausea, vomiting, malaise, weight loss
>70% will have:
♦️Leukocytosis
♦️Elevated alkaline phosphatase
♦️Anemia
♦️Hypoalbuminemia
>70% will have:
♦️Leukocytosis
♦️Elevated alkaline phosphatase
♦️Anemia
♦️Hypoalbuminemia
9/Sensitivity of contrast-enhanced CT ~95% vs 70-90% for ultrasound.
Some management tips:
🔸Source control ➡️ key
🔸Abscesses <5cm may be cured by aspiration or antibiotics alone
🔸Give antibiotics early, IV first➡️ then PO step down
Some management tips:
🔸Source control ➡️ key
🔸Abscesses <5cm may be cured by aspiration or antibiotics alone
🔸Give antibiotics early, IV first➡️ then PO step down
10/Antibiotic therapy should target GI flora:
🦠E. coli and K. pneumoniae (most common)
🦠Enterococci spp
🦠Streptococcus anginosus group + other viridans group strep
🦠Bacteroides spp
20-50% of infections are polymicrobial
🦠E. coli and K. pneumoniae (most common)
🦠Enterococci spp
🦠Streptococcus anginosus group + other viridans group strep
🦠Bacteroides spp
20-50% of infections are polymicrobial
11/Back to our patient with hypermucoviscous K. pneumoniae (hvKp)…
🔸First described in Taiwan in 1980s
🔸More common in Asia than Europe or US
🔸Causes invasive disease in immunocompetent patients
🔸Mortality up to 35%
🔸First described in Taiwan in 1980s
🔸More common in Asia than Europe or US
🔸Causes invasive disease in immunocompetent patients
🔸Mortality up to 35%
12/Metastases from the primary site of hvKp infection is seen in 12-28% of cases.
Eyes, CNS, lungs ➡️most commonly involved.
70% of patients with CNS or eye disease develop long term sequelae.
Eyes, CNS, lungs ➡️most commonly involved.
70% of patients with CNS or eye disease develop long term sequelae.
13/Empiric treatment considerations include:
🔸Local resistance patterns
🔸Site of metastatic disease and antibiotic penetration
🔸Local resistance patterns
🔸Site of metastatic disease and antibiotic penetration
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