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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.