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.