3-in-1: bilateral subcutaneous leg abscesses and liver abscess from Klebsiella pneumoniae

Abstract

Hypervirulent strains of Klebsiella pneumoniae are known to cause liver abscesses and other metastatic infections. Being Asian and having diabetes are known host risk factors. Here we present an unusual case of a Filipino ballet dancer-choreographer with diabetes presenting with bilateral leg pains initially thought to be cellulitis, but was eventually diagnosed as bilateral subcutaneous leg abscesses. He also had a liver abscess, thankfully asymptomatic, which was only discovered on imaging. The occurrence of three distant abscesses in one patient, hence '3-in-1,' makes this case worth reporting. Bilateral subcutaneous leg abscesses as the presenting manifestation of this infection have not been reported yet. We hypothesise that his occupation which makes use of frequent contractions of leg muscles led to increased blood flow and preferentially directed blood-borne bacteria to localise in both legs. We have also characterised the pathogen with regards to its hypermucoviscous phenotype, capsular type, virulence genes and phylogeny.

Keywords: diabetes; infectious diseases.

Figure 1

CT (axial view) of both legs shows collection of pus in the subcutaneous region delineated by green line.

Figure 2

CT (sagittal view) of leg shows collection of pus in the subcutaneous region delineated by red line.

Figure 3

Triphasic CT of the abdomen shows a peripherally enhancing hypodense lobulated mass in segments 6 and 7 of the liver measuring about 4.2×4.3×3.4 cm (craniocaudal×transverse×anteroposterior), assessed to be a liver abscess.

Figure 4

Pus draining from the left leg during incision and drainage.

Figure 5

Serial liver ultrasound demonstrating reduction in size and echogenicity of the liver abscess.

Figure 6

String test performed on the bacterial colony of Klebsiella pneumoniae shows it to have the hypermucoviscous phenotype.

Figure 7

Neighbour joining tree made from concatenated sequences of Klebsiella pneumoniae. Sample CA18 (the bacterial isolate in this case) can be seen to clad with sequence type (ST) 14 (see red line). Unrooted tree was generated by Angelo dela Tonga using SplitsTree4 using 76 different STs and the sample.