The Journal of Emergency Medicine, Vol. 52, No. 6, pp.

e221e223, 2017
2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2017.01.043

Clinical
Communications: Adult

MORE THAN MEETS THE EYE: KLEBSIELLA PNEUMONIAE INVASIVE LIVER

ABSCESS SYNDROME PRESENTING WITH ENDOPHTHALMITIS

Jan Van Keer, MD,* Karel Van Keer, MD, Joachim Van Calster, MD, and Inge Derdelinckx, MD, PHD*
*Department of Internal Medicine and Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
Reprint Address: Jan Van Keer, MD, Department of Internal Medicine, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium

, AbstractBackground: Endophthalmitis is a feared syndrome consisting of a liver abscess with extrahepatic

complication of pyogenic liver abscesses caused by hypervir-
ulent Klebsiella pneumoniae strains. First described in East
Asia in the 1980s, this invasive syndrome is only recently
emerging in Europe and America. Case Report: We describe
an 84-year-old man who presented to the emergency depart-
ment with fever, orbital cellulitis, and bilateral visual loss.
Although the patient had no overt abdominal symptoms,
computed tomography scan revealed a pyogenic liver ab-
scess. Blood cultures were positive for K. pneumoniae. Initial
treatment consisted of intravenous ceftriaxone and intravi-
treal ceftazidime. A unilateral vitrectomy was performed.
The patient survived with severe visual sequelae. Why
Should An Emergency Physician Be Aware of This?: K.
pneumoniae pyogenic liver abscess with metastatic endoph-
thalmitis is a relatively new syndrome that should be consid-
ered in patients presenting with acute vision loss who appear
septic, with or without abdominal complaints. Early recog-
nition prohibits delays in lifesaving treatment. 2017
Elsevier Inc. All rights reserved.
, Keywordsendophthalmitis; liver abscess; Klebsiella
pneumoniae; invasive liver abscess syndrome
INTRODUCTION
Klebsiella pneumoniae is a well-known human pathogen,
usually causing pneumonia or urinary tract infections.
Hypervirulent K. pneumoniae strains can cause a distinct
Written informed consent was obtained from the patient for
publication of this case report and the accompanying images.
manifestations, such as endophthalmitis, meningitis, or
necrotizing fasciitis (13). This syndrome was first
described in East Asia two decades ago and is emerging
in Europe and America only recently (1,4,5). We
describe a patient with a K. pneumoniae liver abscess
and bilateral endophthalmitis, presenting to the
emergency department (ED) with fever and sudden
vision loss.
CASE REPORT
A previously healthy, 84-year-old farmer presented with
sudden bilateral vision loss, painful swelling of the right
eye, and high-grade fever of 1 day duration. The medical
history was positive for bilateral cataract surgery 17 years
earlier, prostate carcinoma that had been treated with
radical prostatectomy 5 years earlier, and hypertension
for which the patient took lisinopril and bisoprolol. On
clinical examination, the patient appeared ill, with a fever
of 39.9 C, blood pressure of 119/73 mm Hg, and heart
rate of 105 beats/min. The physical examination of the
heart and lungs was unremarkable.
On abdominal examination, there was mild right upper
quadrant tenderness without guarding or rebound tender-
ness. The most striking physical finding was proptosis
and lid erythema of the right eye (Figure 1A). Visual acu-
ity was severely reduced in both eyes: 20/250 in the left
eye and counting fingers at 0.5 m in the right eye.
Ophthalmologic examination with fundoscopy and

RECEIVED: 6 December 2016; FINAL SUBMISSION RECEIVED: 13 January 2017;

ACCEPTED: 27 January 2017

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Figure 1. (A) Right orbital cellulitis. (B) Fundoscopy: bilateral (only left eye shown) endophthalmitis. (C) Computed tomographic
image of pyogenic liver abscess.
ultrasound revealed bilateral diffuse vitritis and retinitis
(Figure 1B). Laboratory tests revealed a white blood
cell count of 7.1  109/L (reference value, 4.010.0)
and C-reactive protein of 343 mg/L (reference value,
< 3.0). Renal, liver, and electrolyte profiles were within
normal ranges. Urinalysis was bland. Chest x-ray study
showed no abnormalities. A computed tomography scan
of the abdomen, which was ordered due to the right upper
quadrant tenderness, revealed a multilocular, hypoattenu-
ating lesion measuring 25 by 29 mm in liver segment 5,
corresponding to a pyogenic liver abscess (Figure 1C).
Blood cultures were positive for K. pneumoniae.
The patient was diagnosed with K. pneumoniae pyo-
genic liver abscess with bilateral metastatic septic en-
dophthalmitis and unilateral orbital cellulitis. Empiric
treatment with intravenous ceftriaxone and intravitreal
injection with ceftazidime was started in the ED. We
J. Van Keer et al.
chose not to perform percutaneous or surgical drainage
of the hepatic abscess, as it was smaller than 30 mm and
systemic response to antibiotic therapy was favorable.
However, despite this, visual acuity of the right eye
rapidly deteriorated to no light perception. To prevent
further visual deterioration in the other eye, a vitrec-
tomy was performed on the left eye on day 3. Systemic
antibiotic therapy was switched to levofloxacin to tran-
sition to oral treatment. After 2 weeks of intravenous
therapy, oral levofloxacin was continued for another
4 weeks. The patient survived but had severe visual
sequelae.
DISCUSSION
This case report describes a K. pneumoniae liver abscess
presenting with sudden bilateral vision loss caused by
Klebsiella pneumoniae Invasive Liver Abscess Syndrome
septic endophthalmitis. K. pneumoniae is a well-known
human pathogen. Most community-acquired K. pneumo-
niae infections cause pneumonia or urinary tract infec-
tions. During the past two decades a new syndrome
has been reported, consisting of a K. pneumoniae liver
abscess with extrahepatic complications, especially en-
dophthalmitis, meningitis, and necrotizing fasciitis
(13). This syndrome has been called invasive liver
abscess syndrome (6). It was first described in East
Asia in the 1980s and is now emerging in Europe and
America (1,4,5). The invasive liver abscess syndrome
is caused by hypervirulent K. pneumoniae strains of
the K1 or K2 serotype with a hypermucoviscous
phenotype (7). K. pneumoniae endophthalmitis should
be considered in patients presenting with sepsis and
acute vision loss. Patients with established septic en-
dophthalmitis should be evaluated for a primary pyo-
genic liver abscess. Conversely, patients with a known
K. pneumoniae liver abscess should be monitored for
ocular symptoms.
The mortality of K. pneumoniae invasive liver abscess
syndrome is between 5% and 10% (4,5,8). Prompt
antibiotic therapy improves prognosis. Third-generation
cephalosporins are the mainstay of treatment (6). Fortu-
nately, extended spectrum b-lactamase-producing strains
are very rare; carbapenems are the drug of choice in these
cases (9). The duration of treatment varies between 2 and
6 weeks, depending on the response to treatment, as
determined by resolution of fever and leukocytosis and
ultrasound of the abscess. In large liver abscesses,
adequate drainage, if possible via percutaneous route, is
recommended (6).
Metastatic infections to the eyes are severe and diffi-
cult to treat. Rapid administration of intravitreal antibi-
otics, preferably ceftazidime, sometimes in combination
with aminoglycosides, is required (10). Early vitrectomy
can improve visual prognosis in selected patients (11).
K. pneumoniae endophthalmitis is often bilateral.
Despite adequate therapy, the visual prognosis is very
poor: more than 85% of patients will have a severe vi-
sual deficit (12).
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WHY SHOULD AN EMERGENCY PHYSICIAN BE
AWARE OF THIS?
K. pneumoniae pyogenic liver abscess with metastatic en-
dophthalmitis constitutes a distinct syndrome, the inva-
sive liver abscess syndrome, that is emerging in the
Western world. The diagnosis should be considered in pa-
tients presenting with acute vision loss who appear septic,
with or without abdominal complaints. Early recognition
in the ED prohibits delays in treatment and improves sur-
vival and visual prognosis.
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