Fulminant Klebssiella Pneumoniae Pneumonia in Immunocompetent Non Alcoholic Patient

We describe a case of fulminant community acquired bacteremic K. pneumoniae pneumonia in non alcoholic (Ͻ20 gr/day) patient. A previously healthy 36-year-old man presented with fever (39 C), malaise, dyspnea and a nonproductive cough. On physical examination, he had tachycardia (120/min), tachypnea (31/min) and hypotension (85/67 mm Hg). A chest radiograph displayed symmetric bilateral and voluminous hyperdense lung consolidation with bulging interlobar fi ssure (Fig. 1A). Blood work showed neutropenia (WBC 3000 counts/ml, Neutrophiles 400), metabolic acidosis (PH 7.1, bicarbon-ate 10, PO 2 70, PCO 2 23) and acute renal failure (Cr 3.8, BUN 76). Within a few hours, the patient's condition deteriorated with sudden onset of acute respiratory distress and shock with disseminated intravascular coagulation (platelets 70,000 counts/ml, D-Dimmers 15, fi brinogen 180 mg/dL, INR 1.5). Despite ventilatory support and the administration of intravenous fl uids, Granulocyte-Macrophage Colony Stimulating Factor, antibiotics (cefuroxime and roxithromycin), and vasopressive agents, the patient died within a few hours. One of two blood cultures later revealed Kliebssiella pneumoniae. Autopsy showed voluminous infl ammatory lung exudate with massive neutrophile infi ltrates fi brin and lung edema (Fig. 1B). Kleb-siella pneumoniae pneumonia is an uncommon community-acquired pneumonia but common nosoco-mial infection. Only four cases of community-acquired bacteremic Klebsiella pneumoniae pneumonia were reported in the 2-year study period in the united state, Argentina, Europe, or Australia; and none were in alcoholics. In contrast, 53 cases of bacteremic Klebsiella pneumoniae pneumonia were observed in South Africa and Taiwan, where an association with alcoholism was observed (1). Three prominent presentations of community–acquired klebsiella infection has been described. First, toxic presentation with sudden onset, high fever, and hemoptysis, chest radiographic abnormalities such as bulging inter-lobar fi ssure and cavitary abscesses are prominent (2). Second, invasive presentation of K. pneumoniae infection with liver abscess has been described in Asia (3). The third striking clinical observation is the preponderance of K. pneumoniae as a cause of community acquired bacterial meningitis in adults in Taiwan, even in the absence of liver abscess or other sites of infection (4). Our case belongs to the fi rst advanced clinical presentation with the formation of voluminous infl ammatory exudates leading to lobar expansion with resulting bulging of interlobar fi ssures. Severe gram-negative infection and gram negative bacteremia are the leading causes of sepsis and septic shock (5). In this disease process, the pathogen and the host's immune response may trigger a cascade of pathophysiologic responses that …