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Q1: How does this woman's diabetes relate to her current infective illness?
Although it is recognised that diabetes can be associated with an increased susceptibility to infections, only a few bacterial infections have been proven to have a higher incidence in diabetic patients.1 These are: staphylococcal infections;Corynebacterium minutissimum causing erythrasma; Pseudomonas aeruginosa causing malignant external otitis; bacteroides and anaerobic streptococci causing non-clostridial gas gangrene; andKlebsiella pneumoniae causing hepatic abscess. A review of reported cases showed that diabetes was an underlying condition in 63% of hepatic abscesses caused by Klebsiella pneumoniae.2There is marked geographical variation. In Taiwan, hepatic abscess caused by Klebsiella pneumoniae has been considered endemic for at least 15 years, presenting as an infectious complication in diabetic patients. Interestingly five cases, all involving diabetic patients, have been reported from Trinidad, which is our patient's country of origin.3
Q2: What was the probable source of herKlebsiella pneumoniaesepticaemia?
Klebsiella pneumoniae hepatic abscess is a rare condition associated with significant mortality. The infection often originates from the biliary tract or the gut.Klebsiella pneumoniae hepatic abscess has been associated with cholelithiasis and acute cholecystitis, carcinoma of the pancreas and the biliary tract, diverticular disease, and carcinoma of the colon. Treatment involves drainage and appropriate antibiotics, as well as screening for and eradicating any potential source of the bacteraemia.4
To identify a source of the Klebsiella pneumoniae septicaemia, an endoscopic retrograde cholangiopancreatogram was performed electively and showed only gallstones. A barium enema was normal. The source was therefore assumed to be cholelithiasis. However, in view of the patient's intercurrent medical conditions, it was felt that the risks of elective cholecystectomy outweighed the risk of recurrentKlebsiella pneumoniae septicaemia.
Q3: What was the cause of her left pyramidal deficit?
Klebsiella pneumoniae hepatic abscess is associated with spread of infection to other organs, including the lung and brain.2 The development of respiratory symptoms and signs was associated with worsening signs of sepsis and so was assumed to reflect spread of infection to the lungs. However, the development of the pyramidal deficit occurred in the context of clinical improvement, and the appearances on computed tomography were more consistent with an area of thrombosis in the right middle cerebral artery territory than with a brain abscess. The pyramidal deficit was therefore assumed to be an incidental thromboembolic event.
Klebsiella pneumoniae hepatic abscess is one of the few bacterial infections proven to be more prevalent in diabetic patients
Diabetic subjects with extensive microvascular and macrovascular complications have significant morbidity associated with septicaemia
Klebsiella pneumoniae hepatic abscess with spread of infection to the lungs.