Klebsiella pneumoniae pneumonia

EASE

Klebsiella pneumoniae pneumonia Simon E. Prince, MS, Karen Ann Dominger, MD, Burke A. Cunha, MD, and Natalie C. Klein, MD, PhD, Mineola and Stony Brook, N.Y.

Klebsiella pneumoniae is an u n c o m m o n cause of community-acquired p n e u m o n i a except in alcoholics. Klebsiella may mimic p u l m o n a r y reactivation tuberculosis because it presents with hemoptysis and cavitaring lesions. Klebsiella pneumoniae is a difficult infection to treat because of the organism's thick capsule. Klebsiella is best treated with third- and fourth-generation cephalosporins, quinolones, or carbapenems. Monotherapy is just as effective as a combination treatment in Klebsiella pneumoniae because newer agents are used. In the past, older agents with less anti-Klebsiella activity were needed for effective treatment. The patient we present was initially thought to have pulmonary tuberculosis, and w h e n found to have Klebsiella pneumoniae, the suggested treatment was monotherapy with ceftriaxone. The patient was treated parenterally initially, and then was treated for 3 weeks with oral ofloxacin. (Heart Lung ® 1997;26:413-7)

lebsiella has been a known human pathogen since the late nineteenth century when it was first isolated by Edwin Klebs. It is often called Friedl~nder's pneumonia, in honor of the first man who identified it as a significant respiratory pathogen back in 1882. Although Klebsiella is most often thought of as a nosocomial pathogen, it can also be a cause of serious infection acquired outside the hospital. It is estimated to be responsible for 6% to 8.6% of communityacquired pneumonias. 1-6 Humans are the primary reservoir for Klebsiella, although these organisms may also be found in soil and water. Klebsiella is a common inhabitant of the u p p e r respiratory tract and the bowel. Nasopharyngeal colonization in the general population has been estimated to be between 1% and 6%. However, the colonization rate is increased in patients who are at an increased risk

K

From the Infectious Disease Division, Winthrop-University Hospital, Mineola, and the School of Medicine, State University of New York, Stony Brook. Reprint requests: BurkeA. Cunha, MD, Chief. Infectious Disease Division, Winthrop-University Hospital, 259 First St., Mineola, NY 11501.

Copyright © 1997by Mosby-YearBook, lncF 0147-9563/97/$5.00+ 0 211/81172

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for Klebsiella pulmonary infections. Whether community~acquired or hospital-borne, these infections typically occur in debilitated p a t i e n t s - especially in alcoholic patients. We present a case of Klebsiella pneumoniae in a patient from E1 Salvador, who was thought to have pulmonary tuberculosis because she presented with hemoptysis and had cavitating lesions develop later.

CASE REPORT A 68-year-old woman from E1 Salvador was in her usual state of good health until 2 days before her hospital admission, when a fever with chills and sweats and hemoptysis suddenly developed. The patient immigrated to the United States 10 years ago, and her medical history was significant only for hypertension. The patient stated she had a fever (never actually taking a temperature) 2 days before admission, with associated intermittent chills and sweats. The next day a cough began that shortly thereafter became productive of pinkishorange sputum accompanied by nonradiating chest pain on the left side. She denied contact with any ill or infected individuals. She denied weight loss and decreased appetite. She smoked one pack of cigarettes per day for 2 years, quitting about 20 years ago, and claimed to be a social drinker. She had been given a Calmette-

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Fig. 1 Chest film at admission with left upper lobe opacity.

Fig. 2 Chest film after therapy showing partial resolution of left upper lobe infiltrates.

Gu~rin bacillus vaccine m a n y years ago in E1 Salvador. The patient, an e l d e r l y Spanish-speaking lady, was coughing and in m i l d respiratory distress when she was seen. Her vital signs were as follows: b l o o d pressure 130/80 mm Hg, pulse 100 beats p e r 414

m i n u t e , 24 r e s p i r a t i o n s p e r m i n u t e , a n d t e m p e r a ~ t u r e 100.2 ° F. Her h e a d , ears, eyes, n o s e , a n d throat exam (HEENT) r e v e a l e d n o coryza, n o rhinorrhea, n o facial pain, a n d only a m i l d l y e r y t h e m a t o u s p h a r y n x w i t h o u t e x u d a t e . T h e n e c k was s u p p l e w i t h o u t l y m p h a d e n o p a t h y . E x a m i n a t i o n of h e r SEPTEMBER/OCTOBER 1997 HEART & L U N G

Table I I n f e c t i o u s c a u s e s of c a v i t a r y l u n g l e s i o n s

Rapid cavitation (< 3 d a y s )

Modified rapid cavitation (3-5 d a y s )

Slow cavitation

Staphylococcus aureus Pseudomonas aeruginosa

Klebsiella pneumoniae

Tuberculosis Histoplasmosis Blastomycosis

Septic pulmonary emboli

(> 5 d a y s )

Aspergillus Nocardia Sporotrichosis* Coccidioidomycosis* Atypical tuberculosis* Melioidosis Paragonimiasis* Adapted from Cunha BA. Laboratory clues to the diagnosis pneumonia. In: Karetsky M, Cunha BA, Brandstetter B, editors. The pneumonias. New York: Springer-Verlag; 1993.p. 106-44. By permission. *Initially thin-walled cavities.

chest revealed symmetric breasts, without palpation of a n y m a s s e s . A u s c u l t a t i o n of lungs r e v e a l e d a d e c r e a s e in b r e a t h s o u n d s in t h e left u p p e r l o b e , with s o m e a s s o c i a t e d e g o p h o n y as well. H e a r t s o u n d s w e r e n o r m a l w i t h o u t a murmur, rub, or gallop. T h e a b d o m e n w a s soft, n o n t e n d e r , a n d nondistended. There were normal bowel sounds, n o h e p a t o s p l e n o m e g a l y , a n d n o rigidity, r e b o u n d t e n d e r n e s s , or g u a r d i n g . T h e r e was full r a n g e of m o t i o n of all four e x t r e m i t i e s , w i t h o u t a n y c l u b bing, c y a n o s i s , or e d e m a . S h e was awake, alert, a n d o r i e n t e d , a n d t h e r e s u l t s of h e r n e u r o l o g i c e x a m i n a t i o n w e r e normal. T h e c h e s t r a d i o g r a p h s h o w e d a large left u p p e r l o b e infiltrate (Fig. 1). B e c a u s e of t h e c o n c e r n t h a t this p a t i e n t m i g h t h a v e p u l m o n a r y t u b e r c u l o s i s , s h e was a s s i g n e d to r e s p i r a t o w i s o l a t i o n , a n d s p u t u m was s e n t for G r a m stain a n d a r o u t i n e acidfast b a c i l l i (AFB) culture. B l o o d c u l t u r e s w e r e o b t a i n e d , a n d a PPD with a n e r g y p a n e l was d o n e . The p a t i e n t was g i v e n c e f t r i a x o n e , 1 g m intrav e n o u s l y e v e r y 24 hours, for c o m m u n i t y - a c q u i r e d pneumonia. That night, t h e p a t i e n t s p i k e d a t e m p e r a t u r e of 102.8 ° F, a n d h e r p u l s e was 112 b e a t s p e r m i n u t e . S h e h a d chills a n d s w e a t s a n d c o n t i n u e d to prow d u c e b l o o d - t i n g e d s p u t u m . The next d a y a c o m p u t e d t o m o g r a p h y scan of t h e c h e s t s h o w e d a large i n f i l t r a t e - - 1 4 x l 2 x 6 c m - - i n v o l v i n g m o s t of t h e left u p p e r l o b e a n d lingula. S p u t u m G r a m stain r e v e a l e d a b u n d a n t w h i t e b l o o d ceils a n d g r a m - n e g a t i v e rods, t h e AFB stain was n e g a t i v e . T h e n e x t d a y t h e p a t i e n t was a little b e t t e r . T h e c o u g h was p e r s i s t e n t , b u t its i n t e n s i t y h a d l e s s e n e d , a n d t h e r e was l e s s b l o o d in t h e s p u t u m .

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Table II C o m m o n c a u s e s of u p p e r l o b e r a d i o g r a p h i c infiltrates

Infectious

Noninfectious

Tuberculosis Atypical

Lung neoplasms Silicosis

mycobacteria Klebsiella

Sarcoidosis

Histoplasmosis

Eosinophilic granulomas

Coccidiomycosis

Radiation pneumonitis

Proteus

L6ffler's s y n d r o m e Ankylosing spondylitis

Anaerobic aspiration pneumonia

E x t r i n s i c allergic alveolitis Adapted from Cunha BA. Laboratory clues to the diagnosis pneumonia. In: Karetsky M, Cunha BA, Brandstetter B, editors. The pneumonias. New York: Springer-Verlag; 1993.p.I06-44. By permission.

H e r t e m p e r a t u r e was 100.8 ° F. T h e PPD was n e g a tive, with a r e a c t i o n to m u m p s a n d Candida from the anergy panel. Blood cultures were negative, b u t t h e s p u t u m c u l t u r e grew Klebsiella pneumoniae. O v e r t h e n e x t few d a y s , t h e p a t i e n t b e c a m e afebrile. T h r e e s p u t u m s p e c i m e n s for AFB w e r e n e g a t i v e , a n d r e s p i r a t o r y i s o l a t i o n was d i s c o n tinued.

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Five days after admission, a repeat chest radiograph was obtained that showed cavitation in the left uppe r lobe. The patient continued to improve, and ceftriaxone was discontinued; oral ofloxacin was given, to complete a total 3-week course of therapy. Subsequently, a follow-up chest radiograph was taken showing early resolution (Fig. 2). DIFFERENTIAL DIAGNOSTIC CONSIDERATIONS The initial c h e s t r a d i o g r a p h shows an u p p e r l o b e infiltrate in c o n j u n c t i o n with h e m o p t y s i s . T h e r e are s e v e r a l c a u s e s of u p p e r l o b e infiltrates, a n d t h e r e are s e v e r a l d i s e a s e s c a u s i n g cavitation (Table I). W h e n c o m b i n i n g t h e s e two signs, t h e diff e r e n t i a l d i a g r a m is n a r r o w e d to t u b e r c u l o s i s , Klebsiella, or b r o n c h o g e n i c carcinoma. T h e r e are a v a r i e t y of c a u s e s of cavitary lung dise a s e - - b o t h infectious a n d n o n i n f e c t i o u s (Table II). However, p n e u m o c o c c a l p n e u m o n i a d o e s n o t typically b e h a v e in this m a n n e r . Although p n e u m o coccus m a y c a u s e similar s p u t u m findings, it is usually f o u n d o n c h e s t film as a right lower l o b e infiltrate a n d d o e s n o t cavitate. However, p u l m o n a r y t u b e r c u l o s i s a n d n e o p l a s m s d o n o t cavitate in a m a t t e r of days, a n d this s h o u l d b e sufficient to rule out both. The p a t i e n t in this case, who is from E1 S a l v a d o r a n d p r e s e n t s with fever, sweats, an u p p e r l o b e infiltration, a n d s u b s e q u e n t cavitation, m e r i t s serio u s c o n s i d e r a t i o n of a d i a g n o s i s of t u b e r c u l o s i s - e v e n t h o u g h t h e sweats were n o t truly d e s c r i b e d as night sweats, a n d t h e r e was n o history of weight loss or c o n t a c t with i n f e c t e d i n d i v i d u a l s .

DISCUSSION

Klebsiella pneumoniae, a gram-negative, nonmotile bacillus, is the major pathogen of the genus Klebsiella. It is a lactose-fermenting aerobic organism that is classified by its thick mucoid capsule. There are more than 80 serotypes of Klebsiella pneumoniae, of which K2, K3, and K21 are the most commonly isolated. T h e disease is typically acute and severe at onset, with a sudden appearance of cough, pleuritic chest pain, dyspnea, fever, and rigors. There is a necrotizing inflammatory process that can culminate in the classic thick, bloody, "currant jelly" sputum. Fever, tachypnea, and lung consolidation are usual features on physical examination. The radiographic appearance is typically that of a swollen consolidated lobe, with "bowing" of the fissure (bulging fissure sign) downward due to the dense infiltrate. This is also a predilection for the upper lobes, especially the posterior

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segment of the right upper lobe. There is a tendency towards empyema, with pleural effusions being relatively uncommon. Cavitation is the radiographic hallmark of Klebsiella pneumoniae pneumonia due to its necrotizing tendency. Cavitating usually occurs 3 to 5 days after clinical presentation (Table II). The diagnosis of Klebsiella pneumoniae pneumonia is suggested by the findings of abundant white blood cells and plump gram-negative rods on sputum Gram stain. Definitive diagnosis is made by the recovery of the organisms from the respiratory tract. Blood cultures are frequently positive in approximately 70% of cases. 2"4 The mainstay of treatment is third-generation cephalosporins, carbapenems, and fluoroquinolones. Generally, the length of antibacterial therapy is 2 to 3 weeks of intravenous or oral therapy antibiotics, or both. Previously, two antibiotics were needed to treat Klebsiella pneumonias. This was necessary because they were much less active against Klebsiella pneumoniae than the newer agents mentioned. The mortality rate from Klebsiella pneumonia is quite significant. In the pre-antibiotic era, classic Klebsiella pneumonia was considered almost uniformly fatal. The use of antibiotic therapy has markedly decreased the deaths secondary to Klebsiella. However, the mortality rate is still estimated as high as 54% (higher with alcoholic patient subpopulations). Rarely, there are metastatic complications of Klebsiella pneumonia including pericarditis, arthritis, and meningitis. The more common complications are local pulmonary necrosis, with lung destruction leading to cavitation or, rarely, pulmonary gangrene. A poor prognosis is usually associated with severe underlying medical diseases or inadequate therapy. ~-6 This patient presented with a cough productive of bloody sputum and radiographic findings of an upper lobe opacity with subsequent cavitation. Although hemoptysis in a patient from E1 Salvador might suggest tuberculosis initially, the patient had no weight loss, and did not present with cavitating lesions, but they developed subsequently during hospitalization. Again, in a patient with pneumonia, fever, product!ve cough, acute cavitation and hemoptysis, the most likely cause is an infectious pulmonary disorder, for example, Klebsiella or tuberculosis; but another cause of hemoptysis could be pulmonary neoplasms.

SEPTEMBER/OCTOBER 1997 HEART & LUNG

2. Garb IL, Brown RB, Garb JR, Tuthill RW. Differences in etiology of pneumonia in nursing home and community patients. JAMA 1978;240:2169~72. 3. Cryz SJ Jr. KlebsieUapneumonia. In: Chmel H, Bendinelli M, Friedman H, editors. Pulmonary infections and immunity. New York: Plenum Press; 1994.p.85~94. 4. PierceAK, Sanford JP. Aerobic gram-negative bacillary pneumonias. Am Rev Respir Dis 1974;! I0:647~58. 5. Jong GM, Hsiue TR, Chen CR, Chang HY, Chen CW. Rapidly fatal outcome of bacteremic KlebsieIlapneumoniae pneumonia in alcoholics. Chest 1995:107:214~7. 6. Yinnon AM, Butnaru A, Raveh D, Jerassy Z, Rudensky B. KIebsiella bacteraemia: community versus nosocomial infection. QJM 1996;89:933-41.

T h e lack of w e i g h t loss a n d an i n t a c t a p p e t i t e , p l u s t h e p o s i t i v e s p u t u m c u l t u r e in a p a t i e n t w i t h fever and rapid cavitation, points away from tuberculosis and neoplasm, and supports the d i a g n o s i s of Klebsiella pneumoniae p n e u m o n i a .

REFERENCES 1. Cunha BA. Laboratory clues to the diagnosis pneumonia. In: Karetsky M, Cunha BA, Brandstetter B, editors. The pneumonias. New York: Springer~Verlag;1993.p.106-44.

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