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• W2102894647 abstract "We describe the first documented case of mycotic aneurysm caused by gas-forming serotype K5, and rmpA and iuc positive Klebsiella pneumonia with a hypermucoviscosity phenotype in a diabetic patient. The patient received ceftriaxone for one month and underwent aorto-bi-iliac grafting and inferior mesenteric artery reimplantation and recovered well. We describe the first documented case of mycotic aneurysm caused by gas-forming serotype K5, and rmpA and iuc positive Klebsiella pneumonia with a hypermucoviscosity phenotype in a diabetic patient. The patient received ceftriaxone for one month and underwent aorto-bi-iliac grafting and inferior mesenteric artery reimplantation and recovered well. Mycotic aneurysm caused by gas-forming Klebsiella pneumoniae has rarely been reported.1Lee C.H. Su L.H. Chia J.H. Tsai K.T. Wu T.L. Liu J.W. Recurrent Klebsiella pneumoniae mycotic aneurysm in a diabetic patient and emergence of an extended-spectrum beta-lactamase (CTX-M-24)-containing Klebsiella pneumoniae strain after prolonged treatment with first-generation cephalosporins for mycotic aneurysm.Microb Drug Resist. 2004; 10: 359-363Crossref PubMed Scopus (12) Google Scholar, 2Lai C.P. Wang J.H. Chou T.W. Tseng W.P. Klebsiella pneumoniae-induced mycotic aneurysm of the abdominal aorta complicated by bloody pleural effusion-a case report.Jpn Circ J. 1996; 60: 703-706Crossref PubMed Scopus (5) Google Scholar, 3Isaka N. Tanaka R. Nakamura M. Sugawa M. Konishi T. Nakano T. et al.A case of infectious pseudoaneurysm of the abdominal aorta associated with infectious spondylitis due to Klebsiella pneumoniae.Jpn J Med. 1989; 28: 402-405Crossref PubMed Scopus (14) Google Scholar, 4Tatebe S. Kanazawa H. Yamazaki Y. Aoki E. Sakurai Y. Mycotic aneurysm of the internal iliac artery caused by Klebsiella pneumoniae.Vasa. 1996; 25: 184-187PubMed Google Scholar, 5Cheng H.K.H. Shyu K.G. Lin C.C. Chang H. Leu M.R. Hung C.R. Successful management of ruptured myocotic aneurysm with retroperitoneal abscess due to Klebsiella pneumoniae.J Emerg Crit Care Med. 1996; 7: 166-169Google Scholar, 6Totsugawa T. Kuinose M. Yoshitaka H. Tsushima Y. Ishida A. Minami H. Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in-situ replacement with rifampicin-bonded prosthesis: report of 3 cases.Circ J. 2007; 71: 1317-1320Crossref PubMed Scopus (10) Google Scholar We describe a 48-year-old man who had a long history of diabetes mellitus without medical control. Ten days before admittance, he attended our emergency department after experiencing fever and headache for one week. Chest X-rays showed no pneumonia patch and urinalysis revealed no pyuria. Lumbar puncture was performed for suspected meningitis; the cerebrospinal fluid was clear. His white blood cell count was 8.28 × 109/l (72.3% neutrophils), C-reactive protein was 22 mg/dl (reference range <0.8 mg/dl), blood sugar level was 304 mg/dl and two sets of blood culture yielded no bacteria. Anti-HIV and VDRL were negative. Intravenous ceftriaxone (2 g every 12 hr) was administered and his fever subsided gradually. He was willing to be discharged after a three-day course of antibiotic treatment. The fever relapsed one week later and the patient started to suffer from intermittent abdominal pain. He also complained of nausea with vomiting and constipation. White blood cell count was 14.44 × 109/l (81.7% neutrophils) and C-reactive protein was 15.57 mg/dl. Supine abdominal radiography revealed increased bowel gas without definite abnormal gas patterns. Some fecal material was also noted. He still felt abdominal discomfort despite an enema. Abdominal computed tomography (CT) was arranged for suspected intra-abdominal infection, revealing an air pocket at the abdominal aorta near the iliac bifurcation (Figure 1A ). Mycotic aneurysm was strongly suspected and intravenous ceftriaxone (2 g every 12 hr) was administered. Two sets of blood culture yielded K. pneumoniae that was shown to be susceptible to cefazolin, cefmetazole, ceftriaxone and ciprofloxacin, but resistant to ampicillin using the standard disk diffusion method. One month after antibiotic treatment of mycotic aneurysm, abdominal CT showed a 4.2 × 4.0 cm aneurysm at the distal abdominal aorta (Figure 1B). The patient underwent aorto-bi-iliac grafting and inferior mesenteric artery (IMA) reimplantation. No further discomfort was reported and the patient was discharged home without obvious sequel. The final pathology report disclosed necrotizing inflammation, organized hematoma and bacterial clumps in the aortic wall, which are compatible with mycotic aneurysm. Cholesterol granulomas were also noted in the sclerotic wall, indicative of underlying atherosclerosis. Strains of Salmonella species are the most common pathogens in infected aortic aneurysms.7Hsu R.B. Lin F.Y. Psoas abscess in patients with an infected aortic aneurysm.J Vasc Surg. 2007; 46: 230-235Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Mycotic aneurysm caused by K. pneumoniae has rarely been reported in the English-language literature. Cases of K. pneumoniae mycotic aneurysm for which clinical information was available were mostly reported from eastern Asia, including Japan and Taiwan, and the majority of these patients had diabetes mellitus.1Lee C.H. Su L.H. Chia J.H. Tsai K.T. Wu T.L. Liu J.W. Recurrent Klebsiella pneumoniae mycotic aneurysm in a diabetic patient and emergence of an extended-spectrum beta-lactamase (CTX-M-24)-containing Klebsiella pneumoniae strain after prolonged treatment with first-generation cephalosporins for mycotic aneurysm.Microb Drug Resist. 2004; 10: 359-363Crossref PubMed Scopus (12) Google Scholar, 2Lai C.P. Wang J.H. Chou T.W. Tseng W.P. Klebsiella pneumoniae-induced mycotic aneurysm of the abdominal aorta complicated by bloody pleural effusion-a case report.Jpn Circ J. 1996; 60: 703-706Crossref PubMed Scopus (5) Google Scholar, 3Isaka N. Tanaka R. Nakamura M. Sugawa M. Konishi T. Nakano T. et al.A case of infectious pseudoaneurysm of the abdominal aorta associated with infectious spondylitis due to Klebsiella pneumoniae.Jpn J Med. 1989; 28: 402-405Crossref PubMed Scopus (14) Google Scholar, 4Tatebe S. Kanazawa H. Yamazaki Y. Aoki E. Sakurai Y. Mycotic aneurysm of the internal iliac artery caused by Klebsiella pneumoniae.Vasa. 1996; 25: 184-187PubMed Google Scholar, 5Cheng H.K.H. Shyu K.G. Lin C.C. Chang H. Leu M.R. Hung C.R. Successful management of ruptured myocotic aneurysm with retroperitoneal abscess due to Klebsiella pneumoniae.J Emerg Crit Care Med. 1996; 7: 166-169Google Scholar, 6Totsugawa T. Kuinose M. Yoshitaka H. Tsushima Y. Ishida A. Minami H. Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in-situ replacement with rifampicin-bonded prosthesis: report of 3 cases.Circ J. 2007; 71: 1317-1320Crossref PubMed Scopus (10) Google Scholar However, none of them had gas-forming lesions in the infected aorta. The pathophysiology of mycotic aneurysm consists of bacteremia with septic emboli and subsequent arterial wall invasion, local proliferation of adjacent infectious lesion and pathogens lodging in pre-existing aortic aneurysms in patients with predisposing factors, such as hypertension, hyperlipidemia and diabetes mellitus.8Chen I.M. Chang H.H. Hsu C.P. Lai S.T. Shih C.C. Ten-year experience with surgical repair of mycotic aortic aneurysms.J Chin Med Assoc. 2005; 68: 265-271Abstract Full Text PDF PubMed Scopus (47) Google Scholar In our patient, diabetes mellitus without control is the most prominent risk factor of mycotic aneurysm, especially that caused by K. pneumoniae. The K. pneumoniae isolate recovered from this patient exhibited hypermucoviscosity phenotype, K5 serotype, and was rmpA and iuc positive. The pathogenic role of this phenotype/genotype associated with mycotic aneurysm in our patient is unknown. Recently, capsular serotype K1 or K2 and iron uptake gene clusters (e.g. iuc), rather than magA and rmpA, have been documented as major virulence determinants of liver abscesses in Taiwan .9Yeh K.M. Kurup A. Siu L.K. Koh Y.L. Fung C.P. Lin J.C. et al.Capsular serotype K1 or K2, rather than magA and rmpA, is a major virulence determinant for Klebsiella pneumoniae liver abscess in Singapore and Taiwan.J Clin Microbiol. 2007; 45: 466-471Crossref PubMed Scopus (225) Google Scholar, 10Hsieh P.F. Lin T.L. Lee C.Z. Tsai S.F. Wang J.T. Serum-induced iron-acquisition systems and TonB contribute to virulence in Klebsiella pneumoniae causing primary pyogenic liver abscess.J Infect Dis. 2008; 197: 1717-1727Crossref PubMed Scopus (153) Google Scholar In conclusion, this is the first documented case of mycotic aneurysm caused by gas-forming serotype K5 K. pneumoniae in a diabetic patient. Early diagnosis, adequate antibiotic treatment and surgical intervention are important for emergency physicians to manage this rare but life-threatening disease. Conflict of interest: No conflict of interest to declare." @default.
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