IF: 0.644
REUTERS THOMSON

Necrotizing Fasciitis Caused by Klebsiella pneumoniae in a Patient Undergoing Hemodialysis: A Case Report and Literature Review

AUTHORS

Jun-Li Tsai 1 , Shang-Feng Tsai 2 , 3 , 4 , *

AUTHORS INFORMATION

1 Department of family medicine, Cheng Ching General Hospital, Taichung, Taiwan

2 Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan

3 School of Medicine, China Medical University, Taichung, Taiwan

4 Department of Life Science, Tunghai University, Taichung, Taiwan

How to Cite: Tsai J, Tsai S. Necrotizing Fasciitis Caused by Klebsiella pneumoniae in a Patient Undergoing Hemodialysis: A Case Report and Literature Review, Iran Red Crescent Med J. 2018 ; 20(7):e62067. doi: 10.5812/ircmj.62067.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 20 (7); e62067
Published Online: May 7, 2018
Article Type: Case Report
Received: September 22, 2017
Revised: November 11, 2017
Accepted: February 5, 2018
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Introduction: Necrotizing fasciitis is not rare in clinical practice, but a Klebsiella pneumoniae-related is rare, especially in patients undergoing hemodialysis. Many patients with necrotizing fasciitis have a miserable outcome even though they receive amputation.

Case Presentation: A 76-year-old male was initially admitted to the center due to suspected cellulitis in Taichung, Taiwan. However, the treatment response was beyond expectation, and a plain film X-ray was performed on his leg. To our surprise, it showed apparent gas and calciphylaxis. Easy examination detected the severe disease. Immediate surgical debridement was performed, and his legs and life were successfully saved, although the outcomes of the disease were miserable. The tissue culture yielded Klebsiella pneumoniae. This pathogen, related to necrotizing fasciitis, is rare in the currently published articles. The possible risk factors were the endemic region, diabetes mellitus, calciphylaxis, old age, frequent iron supplements, and repeated tissue hypoperfusion during hemodialysis.

Conclusion: In conclusion, meticulously and timely diagnosed necrotizing fasciitis in high-risk groups is the most important factor to ensure a positive patient outcome.

Keywords

Calciphylaxis Cellulitis Fasciitis Hemodialysis Klebsiella pneumoniae Necrotizing

Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Introduction

Necrotizing fasciitis (NF) is not rare in clinical practice, but NF caused by Klebsiella pneumoniae (KP) is still rare. The outcome of NF is miserable in the general population, but the outcome NF caused by KP is still undefined, especially in uremic populations. Here is the report on the first case of a uremic patient with NF caused by KP. The risk factors for this patient were reviewed, and the unique characteristics of this patient were discussed. The importance of early diagnosis for such populations was highlighted; clinicians should keep in mind this diagnosis even if it is a rarity.

2. Case Presentation

A 76-year-old male had a history of coronary artery disease, type 2 diabetes mellitus (DM), and end-stage renal disease undergoing regular hemodialysis for ten years. This time, he was admitted to Taichung Veterans General Hospital in Taiwan in 2012 due to right leg erythema and swelling, for four days. He had chronic uremic pruritus and used to scratch his leg. Right leg swelling, erythematous change, and a painful sensation were noticed. Therefore, he was admitted to the emergency department, but there was no leukocytosis or thrombocytopenia, and the hemodynamic status was also stable. However, C-reactive protein (CRP) was up to 11.9 mg/dL. Ampicillin-sulbactam was prescribed for suspected soft tissue infection. After three days of antibiotic therapy, he claimed the painful sensation, and the swelling even got worse. There were no bullae or increased area of erythema (Figure 1A), but due to unexplained painful sensations, a plain X-ray of the right lower limb was taken. Surprisingly, X-ray imaging revealed calciphylaxis and multiloculated low attenuation lesions within the soft tissue of the right middle calf (Figure 1B). Computed tomography (CT) disclosed fluid accumulation with gas formation between the tibia and fibula of the right lower leg, 156 mm in diameter, compatible with abscess formation and necrotizing fasciitis (Figure 1C, D, E, and F). After studying the images, only crepitus with very deep palpitation could be detected by examinations. The important data are summarized in Table 1.

Necrotizing fasciitis of gross picture, plain X ray and computed tomography
Figure 1. Necrotizing fasciitis of gross picture, plain X ray and computed tomography
Table 1. Patient’s Characteristics
CharacteristicsData
Age76 Years old
Body weight, height, and BMI70 kg, 170 cm, 24.2 kg/m2
Underlying diseasesCoronary artery disease for 5 years; Type 2 diabetes mellitus for 30 years; End-stage renal disease undergoing regular hemodialysis for ten years
Systolic and diastolic blood pressure135/70 mmHg
White blood cell25000/µL
Neutrophil95%
CRP11.9 mg/dL
Microbiological analysisKlebsiella pneumoniae
Calcium, phosphate, and intact PTH6.5 mg/dL, 6.1 mg/dL, 600 ug/L

Soon, debridement was performed on the same day. Perioperatively, a much purulent discharge was found. The culture yielded KP that was resistant to ampicillin-sulbactam. Flomoxef was applied with a wet wound dressing for three weeks. Moreover, there was no liver abscess and endophthalmitis. A split-thickness graft was applied later, and he recovered fully after one month. The present report was approved by the patient himself and he signed the informed consent.

3. Discussion

NF caused by KP is very rare and rarer still in uremic patients. In addition, most cases occurred in Asia (1), especially in Taiwan (2). However, in recent years such reports are more frequent, probably in association with the highly virulent capsular serotype K1 of KP. The most common NF cases caused by KP are over lower extremities (2), which is compatible with the current case report. In addition to the endemic area of KP infection, the studied patient had many risk factors as follows: a weak immune system predisposed the patient to a rare infection (3). Also, uremic patients usually take iron supplement due to iron deficiency anemia, but iron is essential for bacterial growth and replication (4). The current case took an iron supplement (100 mg per day), which is also a risk factor for KP infection., The patient with uremia underwent regular hemodialysis, which caused hypoperfusion (5). Fluctuating hemodynamic change during hemodialysis might contribute to systemic hypoperfusion and further compromise visceral circulation. The situation facilitated the proliferation of gas-forming organisms and bacterial translocation in his thighs (6). Moreover, he had calciphylaxis (Figure 1B). The calcific uremic arteriolopathy made him more susceptible to infection. Finally, DM is a substantial risk factor for almost all infections (7), particularly for KP infection (8).

Table 2. Clinical Profiles and Outcomes of Necrotizing Fasciitis Caused by Klebsiella pneumoniae
CasesAge/GenderUnderlying DiseasePresentationCultureSuperimposed InfectionTreatmentOutcome
Case 1 (10)50/MCirrhosis, child C, edema, vascular diseaseSoft tissueHepatic abscessUnknownCured
Case 2 (10)55/FCirrhosis, child C, edema, vascular diseaseBullous lesions, extensive cutaneous necrosisSoft tissue, bloodNoneUnknownExpired
Case 3 (10)57/FCirrhosis, child C, edema, vascular diseaseBullous lesions, extensive cutaneous necrosisSoft tissue, bloodNoneUnknownCured
Case 4 (11)UnknownLiver abscessUnknownUnknownUnknownUnknownUnknown
Case 5 (12)47/MDiabetes mellitusFever, chills, abdominal pain, leg pain/warm/red/ bogginessBlood, hepatic abscess, soft tissueHepatic abscessCefazolin, ciprofloxacin, ceftriaxone; Extensive lateral fasciotomy and drainageCured
Case 6 (13)71/MNoneFever, chills, abdominal pain, painful swelling and erythema with indurationHepatic abscess, soft tissueHepatic, renal, and pancreatic abscess, endogenous endophthalmitisCeftriaxone, drainage and fasciotomyCured
Case 7 (13)40/MDiabetes mellitusFever, chills, painful swelling, severe tendernessBlood and soft tissueHepatic abscess,Cefazolin and gentamicin, fasciotomyCured
Case 8 (14)52/MHBV-cirrhosis, Child C; diabetes mellitusShock, leg pain, purpura, erythema, swelling, and skin necrosisBlood, and soft tissue cultureSpontaneous bacterial peritonitiscefoperazone/ sulbactam*14 days for SBP with bacteremia, then extensive debridement + amoxicillin/clavulanate and ofloxacin *15 daysExpired
Case 9 (14)71/FNoneShock, fever, fluctuant mass, skin necrosisBlood, urine surgical specimenNoneExtensive debridement, vasopressors, steroid, hemodialysis, antibioticsExpired
Case 10 (this case)76/MDiabetes mellitus, hemodialysisLeg pain, swellingSoft tissue onlyNoneAmpicillin-sulbactam, flomoxef, debridementCured

Initially, the outcome of NF caused by KP in the current study patient should be very poor according to the study by Liu et al. (9): anemia (8.9 g/dL), more than 24 hours delay from the onset of symptoms to surgery and age above 60 years. The clues to his NF were only high CRP and unexplained pain even after 3-day antibiotic therapy. He even had no leukocytosis, fever, culture report, crepitus, or bullous lesion. In NF, it relies on very insidious clinical manifestations such as unexplained pain and advanced image studies should be arranged until the exclusion of diagnosis. It was good luck that he still had relatively localized NF and CT study was arranged, and debridement followed immediately after the finding of plain film. Until the diagnosis was made, he still had no other comorbidities. All NF cases caused by KP are summarized in Table 2. Of all ten cases, the current study patient was the eldest (76 y/o) and the only one undergoing hemodialysis. The mortality rate was up to 33.3%, with comorbidities, including cirrhosis (cases 2 and 8) and other infections (bacteremia in cases 2, 8, and 9; and peritonitis in case 8). Therefore, in addition to timely diagnosis and treatment, the area of KP infection should also be considered. Even with delayed diagnosis up to 3 days, the patient’s life could be saved.

In this patient, early detection of necrotizing fasciitis via simple examination (X-ray) was associated with good outcome. Necrotizing fasciitis caused by Klebsiella pneumoniae is rare in patients undergoing hemodialysis. However, despite of its rarity, the diagnosis was timely and accurate.

3.1. Conclusion

NF caused by KP is rared and even rarer in uremic patients. The manifestation may be insidious and only by being alert to the diagnosis, the patients’ lives can be saved. The range of involvement with KP infection is also an important factor for patients’ outcomes.

Footnotes

References

  • 1. Shon AS, Bajwa RP, Russo TA. Hypervirulent (hypermucoviscous) Klebsiella pneumoniae: a new and dangerous breed. Virulence. 2013;4(2):107-18. doi: 10.4161/viru.22718. [PubMed: 23302790].
  • 2. Cheng NC, Yu YC, Tai HC, Hsueh PR, Chang SC, Lai SY, et al. Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis. Clin Infect Dis. 2012;55(7):930-9. doi: 10.1093/cid/cis565. [PubMed: 22715175].
  • 3. Gavazzi G, Krause KH. Ageing and infection. Lancet Infect Diseas. 2002;2(11):659-66.
  • 4. Ward CG, Hammond JS, Bullen JJ. Effect of iron compounds on antibacterial function of human polymorphs and plasma. Infect Immun. 1986;51(3):723-30. [PubMed: 3512430].
  • 5. Hakkarainen TW, Kopari NM, Pham TN, Evans HL. Necrotizing soft tissue infections: review and current concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014;51(8):344-62. doi: 10.1067/j.cpsurg.2014.06.001. [PubMed: 25069713].
  • 6. McIntyre CW. Recurrent circulatory stress: the dark side of dialysis. Semin Dial. 2010;23(5):449-51. doi: 10.1111/j.1525-139X.2010.00782.x. [PubMed: 21039872].
  • 7. Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Infections in patients with diabetes mellitus. N Engl J Med. 1999;341(25):1906-12. doi: 10.1056/NEJM199912163412507. [PubMed: 10601511].
  • 8. Chen SC, Yen CH, Tsao SM, Huang CC, Chen CC, Lee MC, et al. Comparison of pyogenic liver abscesses of biliary and cryptogenic origin. An eight-year analysis in a University Hospital. Swiss Med Wkly. 2005;135(23-24):344-51. [PubMed: 16059789].
  • 9. Liu YM, Chi CY, Ho MW. Microbiology and factors affecting mortality in necrotizing fasciitis. J Microbiol Immunol Infect. 2005;38(6):430-5.
  • 10. Corredoira JM, Ariza J, Pallares R. Gram-negative bacillary cellulitis in patients with hepatic cirrhosis. Europ J Clinical Microbiol Infect Diseas, Official Publicat Europ Societ Clinical Microbiol. 1994;13(1):19-24.
  • 11. Chou FF, Kou HK. Endogenous endophthalmitis associated with pyogenic hepatic abscess. J Am Coll Surg. 1996;182(1):33-6. [PubMed: 8542086].
  • 12. Dylewski JS, Dylewski I. Necrotizing fasciitis with Klebsiella liver abscess. Clinical Infect Diseas Official Publicat Infect Diseas Societ America. 1998;27(6):1561-2.
  • 13. Hu BS, Lau YJ, Shi ZY, Lin YH. Necrotizing fasciitis associated with Klebsiella pneumoniae liver abscess. Clin Infect Dis. 1999;29(5):1360-1. doi: 10.1086/313471. [PubMed: 10525011].
  • 14. Ho PL, Tang WM, Yuen KY. Klebsiella pneumoniae necrotizing fasciitis associated with diabetes and liver cirrhosis. Clin Infect Dis. 2000;30(6):989-90. doi: 10.1086/313791. [PubMed: 10880333].
  • COMMENTS

    LEAVE A COMMENT HERE: