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First description of lung abscess caused by ST23 clone capsule genotype K1 Klebsiella pneumoniae
Journal of the Formosan Medical Association (2015) 114, 379e380
Available online at www.sciencedirect.com
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CORRESPONDENCE
First description of lung abscess caused by ST23 clone capsule genotype K1 Klebsiella pneumoniae Kuo-Chen Cheng a,b,c, Mei-Feng Lee d, Yin-Ching Chuang d,e, Wen-Liang Yu f,g,* a
Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan Department of Safety Health and Environment, Chung Hwa University of Medical Technology, Tainan, Taiwan c Department of Medicine, National Defense Medical Center, Taipei, Taiwan d Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan e Department of Internal Medicine, Chi Mei Hospital, Liouying, Tainan, Taiwan f Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan g Department of Medicine, Taipei Medical University, Taipei, Taiwan b
Received 8 July 2013; received in revised form 8 August 2013; accepted 19 August 2013 Dear Editor, Klebsiella pneumoniae liver abscess is emerging in the world and greater understanding of Klebsiella pathogenesis for liver abscess has focused on the capsule K1 serotype.1 However, primary lung abscess caused by K1 serotype K. pneumoniae in patients without liver abscess has received less attention. An 80-year-old nonalcoholic woman with diabetes mellitus was admitted on October 1, 2012, with fever, hemoptysis, and right chest wall pain for 5 days. The chest X-ray film showed air-space opacities over right lower lung field (Fig. 1A). The computed tomography of the chest showed consolidation with gas-forming abscess on right lower lung (Fig. 1B). No liver abscess was found in the computed tomography series. The patient remained febrile after administration with flomoxef. Both the sputum and pleural effusion cultures Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, 710 Tainan City, Taiwan. E-mail address: [email protected] (W.-L. Yu).
yielded K. pneumoniae, susceptible to cefazoline, cefuroxime, ceftriaxone, flomoxef, and piperacillinetazobactam. The antibiotic was changed to piperacillinetazobactam. Then fever subsided but the lung necrosis progressed (Fig. 1C). After 4-weeks’ piperacillinetazobactam treatment, the consolidation was slowly reduced and central cavitation became prominent (Fig. 1D). The patient was uneventfully discharged on October 29 and she received prolonged oral ciprofloxacin suppression therapy for a total of 5 weeks. Complete resolution of the abscess was gradually achieved about 6 weeks after discontinuing antibiotic (Fig. 1E). The K. pneumoniae isolate was positive for the hypermucoviscosity phenotype (positive string test, >0.5 cm). Genomic DNA was positive for the magA gene, which was specific to K1 capsule genotype.1 Plasmid DNA was positive for the rmpA and rmpA2 genes, which have been significantly correlated to the hypermucoviscosity phenotype of the K. pneumoniae isolates and purulent infections. Multilocus sequence typing (ST) revealed ST23 type. Lin et al2 reported that serotypes K1 (14.3%) and K2 (38.8%) comprised about half of the 49 isolates causing bacteremic community-acquired pneumonia; among them,
0929-6646/$ - see front matter Copyright ª 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2013.08.008
380
K.-C. Cheng et al.
Figure 1 Chest-X-ray films and computed tomography of lung abscess caused by capsule genotype K1 K. pneumoniae. (A) October 1, 2012: shows air-space opacities over right lower lung field. (B) October 1, 2012: chest computed tomography shows suspicious necrotizing pneumonia complicated with abscess over right lower lung field. (C) October 9, 2012: shows progressive lung necrosis formation within the consolidation. (D) October 26, 2012: shows progressive central cavitation in a 6-cm abscess lesion. (E) January 14, 2013: shows complete resolution of the abscess with residual slight infiltration over right lower lung field.
concurrent lung abscess was associated with two isolates of K2 serotype and one isolate of non-K1/K2 serotype. In fact, the cases of lung abscess caused by K. pneumoniae are not uncommon, comprising about 21% and 8.2% of communityacquired lung abscess in Taiwan and Japan, respectively.3,4 However, the distribution of capsular K serotypes among the lung abscess isolates was not determined. ST23 has been recognized as the most prevalent sequence type of serotype K1 K. pneumoniae isolates from both liver abscess and stool samples in Hong Kong, Singapore, and Taiwan.5 Unlike high prevalence in the liver abscess isolates, the ST23 clone capsule K1 K. pneumoniae strain was first reported in the primary lung abscess. In conclusion, we have described a case of primary lung abscess caused by hypermucoviscous and rmpA-positive K. pneumoniae with capsule genotype K1 and ST23 clone. Piperacillin-tazobactam followed by prolonged oral ciprofloxacin therapy can slowly achieve complete resolution of the lesion.
Acknowledgments This study was supported by a research grant (CMFHR10208) from the Chi Mei Medical Center in Tainan, Taiwan.
References 1. Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007;45:284e93. 2. Lin YT, Jeng YY, Chen TL, Fung CP. Bacteremic communityacquired pneumonia due to Klebsiella pneumoniae: clinical and microbiological characteristics in Taiwan, 2001e2008. BMC Infect Dis 2010;10:307. http://dx.doi.org/10.1186/1471-233410-307. 3. Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y. Etiology and outcome of community-acquired lung abscess. Respiration 2010;80:98e105. 4. Wang JL, Chen KY, Fang CT, Hsueh PR, Yang PC, Chang SC. Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes. Clin Infect Dis 2005;40:915e22. 5. Siu LK, Fung CP, Chang FY, Lee N, Yeh KM, Koh TH, et al. Molecular typing and virulence analysis of serotype K1 Klebsiella pneumoniae strains isolated from liver abscess patients and stool samples from noninfectious subjects in Hong Kong, Singapore, and Taiwan. J Clin Microbiol 2011; 49:3761e5.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.jfma-online.com
CORRESPONDENCE
First description of lung abscess caused by ST23 clone capsule genotype K1 Klebsiella pneumoniae Kuo-Chen Cheng a,b,c, Mei-Feng Lee d, Yin-Ching Chuang d,e, Wen-Liang Yu f,g,* a
Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan Department of Safety Health and Environment, Chung Hwa University of Medical Technology, Tainan, Taiwan c Department of Medicine, National Defense Medical Center, Taipei, Taiwan d Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan e Department of Internal Medicine, Chi Mei Hospital, Liouying, Tainan, Taiwan f Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan g Department of Medicine, Taipei Medical University, Taipei, Taiwan b
Received 8 July 2013; received in revised form 8 August 2013; accepted 19 August 2013 Dear Editor, Klebsiella pneumoniae liver abscess is emerging in the world and greater understanding of Klebsiella pathogenesis for liver abscess has focused on the capsule K1 serotype.1 However, primary lung abscess caused by K1 serotype K. pneumoniae in patients without liver abscess has received less attention. An 80-year-old nonalcoholic woman with diabetes mellitus was admitted on October 1, 2012, with fever, hemoptysis, and right chest wall pain for 5 days. The chest X-ray film showed air-space opacities over right lower lung field (Fig. 1A). The computed tomography of the chest showed consolidation with gas-forming abscess on right lower lung (Fig. 1B). No liver abscess was found in the computed tomography series. The patient remained febrile after administration with flomoxef. Both the sputum and pleural effusion cultures Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Zhonghua Road, Yongkang District, 710 Tainan City, Taiwan. E-mail address: [email protected] (W.-L. Yu).
yielded K. pneumoniae, susceptible to cefazoline, cefuroxime, ceftriaxone, flomoxef, and piperacillinetazobactam. The antibiotic was changed to piperacillinetazobactam. Then fever subsided but the lung necrosis progressed (Fig. 1C). After 4-weeks’ piperacillinetazobactam treatment, the consolidation was slowly reduced and central cavitation became prominent (Fig. 1D). The patient was uneventfully discharged on October 29 and she received prolonged oral ciprofloxacin suppression therapy for a total of 5 weeks. Complete resolution of the abscess was gradually achieved about 6 weeks after discontinuing antibiotic (Fig. 1E). The K. pneumoniae isolate was positive for the hypermucoviscosity phenotype (positive string test, >0.5 cm). Genomic DNA was positive for the magA gene, which was specific to K1 capsule genotype.1 Plasmid DNA was positive for the rmpA and rmpA2 genes, which have been significantly correlated to the hypermucoviscosity phenotype of the K. pneumoniae isolates and purulent infections. Multilocus sequence typing (ST) revealed ST23 type. Lin et al2 reported that serotypes K1 (14.3%) and K2 (38.8%) comprised about half of the 49 isolates causing bacteremic community-acquired pneumonia; among them,
0929-6646/$ - see front matter Copyright ª 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2013.08.008
380
K.-C. Cheng et al.
Figure 1 Chest-X-ray films and computed tomography of lung abscess caused by capsule genotype K1 K. pneumoniae. (A) October 1, 2012: shows air-space opacities over right lower lung field. (B) October 1, 2012: chest computed tomography shows suspicious necrotizing pneumonia complicated with abscess over right lower lung field. (C) October 9, 2012: shows progressive lung necrosis formation within the consolidation. (D) October 26, 2012: shows progressive central cavitation in a 6-cm abscess lesion. (E) January 14, 2013: shows complete resolution of the abscess with residual slight infiltration over right lower lung field.
concurrent lung abscess was associated with two isolates of K2 serotype and one isolate of non-K1/K2 serotype. In fact, the cases of lung abscess caused by K. pneumoniae are not uncommon, comprising about 21% and 8.2% of communityacquired lung abscess in Taiwan and Japan, respectively.3,4 However, the distribution of capsular K serotypes among the lung abscess isolates was not determined. ST23 has been recognized as the most prevalent sequence type of serotype K1 K. pneumoniae isolates from both liver abscess and stool samples in Hong Kong, Singapore, and Taiwan.5 Unlike high prevalence in the liver abscess isolates, the ST23 clone capsule K1 K. pneumoniae strain was first reported in the primary lung abscess. In conclusion, we have described a case of primary lung abscess caused by hypermucoviscous and rmpA-positive K. pneumoniae with capsule genotype K1 and ST23 clone. Piperacillin-tazobactam followed by prolonged oral ciprofloxacin therapy can slowly achieve complete resolution of the lesion.
Acknowledgments This study was supported by a research grant (CMFHR10208) from the Chi Mei Medical Center in Tainan, Taiwan.
References 1. Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: an emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007;45:284e93. 2. Lin YT, Jeng YY, Chen TL, Fung CP. Bacteremic communityacquired pneumonia due to Klebsiella pneumoniae: clinical and microbiological characteristics in Taiwan, 2001e2008. BMC Infect Dis 2010;10:307. http://dx.doi.org/10.1186/1471-233410-307. 3. Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y. Etiology and outcome of community-acquired lung abscess. Respiration 2010;80:98e105. 4. Wang JL, Chen KY, Fang CT, Hsueh PR, Yang PC, Chang SC. Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes. Clin Infect Dis 2005;40:915e22. 5. Siu LK, Fung CP, Chang FY, Lee N, Yeh KM, Koh TH, et al. Molecular typing and virulence analysis of serotype K1 Klebsiella pneumoniae strains isolated from liver abscess patients and stool samples from noninfectious subjects in Hong Kong, Singapore, and Taiwan. J Clin Microbiol 2011; 49:3761e5.