Case Report:
A 40-year-old Nepalese male who is known to have diabetes (recently diagnosed (HBa1c-13.6) was brought to the emergency department (ED) by emergency medical services (EMS) due to an episode of acute confusion, headache, and dizziness. On examination, the patient was vitally stable; he was aggressive, disoriented to time and place, and had a low level of conscious level, which led to the patient’s intubation in ED; Emergency Computed tomography scan of head was unremarkable. On review of his blood investigations, his PH was 6.9 (normal is PH 7.35- 7.45) with low bicarbonate of 6 mmol/L (normal bicarbonate level 23-29 mmol/L) and serum Beta-hydroxybutyrate levels of 6.6mmol/l (normal levels 0.4-0.5 mmol/L). Based on these reports, treatment was started for Diabetic ketoacidosis with Intravenous fluids and Intravenous insulin as per local protocol. The patient transferred to the medical intensive care unit (MICU) for further management.
Further investigations showed increase in white blood cell count with value of 15.10^3/uL(normal range is 4-10 x10^3/uL) and C-reactive protein 320 mg/L(0-5mg/L). A chest x-ray showed patchy opacities in both lung fields. After taking samples of blood and urine cultures, empiric antibiotics piperacillin-tazobactam, and clarithromycin started considering the diagnosis of community acquired pneumonia leading to Diabetic ketoacidosis.
On day three of admission blood culture and tracheal aspirate culture grew Klebsiella pneumoniae, which was pan-sensitive, so antibiotics de-escalated to amoxicillin-clavulanate.
In the evening patient’s condition deteriorated with low blood pressure, and he was started on inotropes as per ICU protocol, his abdomen’s ultrasound scan revealed enlarged liver of 17.7cm and an ill-defined complex lesion of 6.3x6x5.1 cm, likely hepatic abscess. (figure 1A). The patient had a Computed tomography scan of abdomen for better characterization of the abscess, which confirmed an abscess in the liver and showed multiple small abscesses in both the kidneys and numerous air pockets of abscess in the right gluteus (figure 2). During the same day, the patient developed anisocoria. The initial Non-contrast Computed tomography scan head was unremarkable. Magnetic resonance scan of head showed septic embolic meningoencephalitis with widespread microhemorrhages (figure 3A). The patient had ultrasound guided drainage of the liver abscess, drain was removed after 48 hours as there was minimal pus coming out of the drain and drained fluid culture also grew Klebsiella pneumoniae. His antibiotics were escalated to meropenem (meningitis dose ), vancomycin, and metronidazole by the infectious disease team. Transthoracic echocardiogram and Transesophageal echocardiogram ruled out any heart valve vegetations. All these tests confirmed that the patient had an embolic spread of Klebsiella infection.
On day ten, the patient became hemodynamically stable, which led to the tapering of inotropes and sedation, but the patient kept on spiking fever despite multiple antibiotics. A repeat ultrasound scan abdomen after 15days of ultrasound-guided liver drainage showed interval regression in liver abscess size 4.4 x 4.8 x 4 cm, the estimated volume of 54cc (figure 1B). After receiving two weeks of antibiotics, the patients blood culture came negative. The patient became afebrile and hemodynamically stable, so antibiotics de-escalated to ceftriaxone and metronidazole.
The patient conscious level remained low (Glasgow coma scale remained low), and the follow-up Magnetic resonance scan of head showed the worsening of micro abscesses (figure 3B), for which the patient had a tracheostomy and continued to have tracheostomy ventilation. The patient received an additional six week of ceftriaxone and metronidazole, he remained afebrile during this period, and he was shifted to a long-term facility for continuity of care.