2009 December Featured Case and 2009 IDSA Fellows' Day Case Presentation M Haghighi MD Shahid Beheshti univesity of medical science This case was originally presented at the Annual Meeting of the Infectious Diseases Society of America 2009 (IDSA, 47th meeting) A man in his sixties was admitted to a hospital because of fevers, dysuria and dark urine. One week earlier, temperatures up to 103104°F (39.4-40.0°C) had developed, associated with dysuria, urinary frequency and dark urine. On the 7th day, he saw his primary care provider. prostatitis was diagnosed and ciprofloxacin (250 mg twice daily) administered. The next day, pleuritic chest pain developed on the right side, associated with mild dyspnea. He was admitted to the hospital. There was no history of cough, sputum production, diarrhea, abdominal pain, or rash. Past medical history /Allergies He had benign prostate hypertrophy. The level of prostate specific antigen (PSA) had been normal during the previous 4 years, most recently 3 months earlier. He had no known drug allergies. Medications Medications included doxazosin and ciprofloxacin. Epidemiological History He was married and had traveled extensively to South America, South Asia, Asia, Mexico, the Pacific Islands, and Australia. Physical Examination The patient appeared ill. The temperature was 102.4°F (39.1°C), pulse 85 beats per minute, blood pressure 128/82 mm Hg and oxygen saturation 98% while breathing ambient air. The mucous membranes were dry. The abdomen was soft, mildly tender in the right upper quadrant, with suprapubic discomfort to palpation. There was no costovertebral angle tenderness. The rectal exam revealed an enlarged and boggy prostate, which was soft and non-tender. The remainder of his examination was normal. Studies The white blood cell count was 17,700 per cubic millimeter (neutrophils 75%, lymphocytes 17% and monocytes 8%) and the hematocrit 34% (reference range 40.7-50.3% in men). The level of serum glucose was 134 mg/dL (ref 65199), alkaline phosphatase 393 IU/L (ref 38-126 IU/L) and albumin of 3.1 g/dL (ref 3.6-5.0 g/dL). The levels of electrolytes, urea nitrogen, creatinine and other tests of liver function were normal. The urinalysis revealed pH 6.0, leukocyte esterase 3+, red cells 3 cells per high-powered field, white cells greater than 50 cells per high-powered field, bacteria 1+, and no nitrites. A radiograph of the chest showed multifocal irregular nodular opacities bilaterally as below: Clinical Course Prior to Diagnosis Vancomycin, ciprofloxacin and cefepime were administered, however, fevers persisted. On the 4th day, tests revealed a persistent leukocytosis, alkaline phosphatase 487 IU/L, aspartate aminotransferase (AST) 83 IU/L (ref 11-47 IU/L), and alanine aminotransferase (ALT) 113 IU/L (ref 7-53 IU/L). Cultures of the blood demonstrated polymicrobial oral flora, which were thought to be contaminants, and culture of a urine specimen was sterile. Computed tomography (CT) of the chest, abdomen and pelvis showed multiple cavitary pulmonary nodules . and an irregular hypodense lesion on right liver lobe, associated with a thrombosed right hepatic vein tributary. Differential Diagnosis Amebic liver abscess Staphylococcus aureus bacteremia with pulmonary emboli Mycobacterium tuberculosis Echinococcus granulosus Bacterial liver abscess and prostatitis Malignancy Disseminated fungal infection Diagnostic Procedures The patient underwent an ultrasound-guided aspiration of the liver abscess. Gram stain of the aspirate revealed a gram negative rod. Specimen grew heavily mucoid pink colonies on MacConkey agar. Hypermucoviscous colonies on MacConkey agar. The "string test", which demonstrates the hyperviscosity is positive. Final Diagnosis Liver abscess caused by hypermucoviscous Klebsiella pneumoniae, associated with prostatitis and pulmonary septic emboli.