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Microbes & Immunity Klebsiella pneumoniae diagnosed by NGS

the Chinese, Taiwanese, Koreans and Japanese, there in segment VI) with untidy margin in both lobes of the
was a disproportionately high incidence of pyogenic liver (Figure 1A and B).
liver abscesses and other pus-forming lesions, such as On day 7 after admission, fever persisted. Blood and
endophthalmitis and pyomyositis, associated with Kp. urine culture showed negative results. The patient’s blood
3-5
Furthermore, these Kp pyogenic liver abscesses were also was sent for mNGS analysis. Contract-enhanced CT scan
strongly associated with diabetes mellitus. In addition of abdomen showed multiple round low-density foci with
6
to this distinct entity of Kp pyogenic liver abscesses in double rim enhancement and untidy margin in the liver
East Asians, this bacterium is also associated with liver and spleen, which were suspected to be hydatid cysts or
abscesses due to recurrent pyogenic cholangitis, another abscesses (Figure 1C-F). Hepatitis A virus immunoglobulin
unique infection in our population due to Clonorchis M (IgM), hepatitis B virus surface antigen, hepatitis C
sinensis infections, pigment stone formation and recurrent virus antibody and hepatitis E virus IgM were negative.
cholangitis of the biliary tree. 7-9 On day 9, mNGS analysis of the blood sample revealed
Diagnosis of Kp liver abscess is usually achieved by 144 sequence reads of Kp. Amoxicillin-clavulanate was
radiological examination and isolation of the bacterium continued, resulting in gradual resolution of her fever
from clinical samples such as blood or pus obtained by and normalization of transaminase levels. Antibodies
drainage. However, in rare situations, when blood culture for Echinococcus granulosus, Schistosomiasis japonicum,
and culture of other clinical specimens were negative, Paragonimus westermani, C. sinensis, Spirometra mansoni,
laboratory diagnosis of Kp liver abscess may be challenging. Taenia solium, and Angiostrongylus cantonensis were
Yet, it is extremely important to distinguish Kp liver abscess negative. Drainage of the lesions in the liver was not
from other culture-negative liver abscess-like lesions, such performed as the patient responded to the antibiotic
as amebic liver abscess, hydatid cyst, or even tumors, as treatment. Amoxicillin-clavulanate was continued for a
treatment of these diseases is radically different. In the past total of 6 weeks. Interval ultrasonographic scan of the
few years, next-generation sequencing (NGS) has emerged liver during and after treatment showed reduction in
as a technology for laboratory diagnosis of many culture- both the size and number of low-density foci in the liver
negative infections. 10-13 In this study, we describe the use (Figure 1G and H). The patient remained asymptomatic
of NGS for rapid diagnosis of Kp culture-negative liver 6 months after discharge.
abscesses. 2.2. Case 2
2. Case presentation An 82-year-old Chinese man was admitted to The
2.1. Case 1 University Hong Kong–Shenzhen Hospital because of
fever, chills, rigor and right upper quadrant abdominal
A 60-year-old Chinese woman was admitted to The pain for 1 day. The patient had histories of hypertension,
University of Hong Kong–Shenzhen Hospital because of a diabetes mellitus and coronary heart disease. He started to
fever for 6 days. Six days before admission, she had acute develop dizziness and vomiting 2 days before admission.
onset of fever and dysuria and was investigated in a clinic. On the day of admission, he developed fever, chills, rigor
Urinalysis and microscopic examination of the urine and severe right upper quadrant pain of the abdomen.
revealed proteinuria, hematuria and white blood cells in His body temperature was 39.6°C. Upper right quadrant
the urine. C-reactive protein (CRP) was 66.9 mg/L. She tenderness was detected. Total white cell count was 10.66
was treated with oral cefuroxime but the fever persisted. × 10 /L, with neutrophils 7.8 × 10 /L. His platelet count
9
9
On admission, her body temperature was 38°C. There was 195 × 10 /L and hemoglobin was 129 g/L. Liver and
9
was no localizing sign. Total white cell count was 11.13 × renal function test results were normal. The prothrombin
10 /L, with neutrophils 8.6 × 10 /L. Her platelet count was time was 13.5 s and the activated partial thromboplastin
9
9
375 × 10 /L and hemoglobin was 112 g/L. Liver enzymes time was prolonged to 50.4 s. His CRP was 215.09 mg/L
9
were mildly elevated. Serum urea and creatinine levels and procalcitonin was 4.42 ng/mL. Contrast CT scan of the
were normal. Random blood glucose was 8.3 mmoL/L. abdomen revealed enlarged gallbladder with cholecystitis,
The oral cefuroxime seemed useless, which could not mild dilation of the intra- and extra-hepatic bile ducts
cover the pathogens, that CRP was elevated. CRP was and pancreatic duct, and multiple round low-density foci
183.5 mg/L. Blood and urine culture were performed with surrounding abnormal perfusion in the liver, which
and empirical intravenous amoxicillin-clavulanate was were suspected to be infected liver cysts with surrounding
commenced. Plain computed tomography (CT) scan of small abscesses (Figure 2A and B). In addition to the
the abdomen revealed multiple round low-density foci of multiple cystic lesions in the liver, ultrasonographic scan
varying sizes (the largest one measuring 32 mm × 16 mm also revealed a stone (7.7 mm × 5.3 mm) and a large

Volume 1 Issue 2 (2024) 95 doi: 10.36922/mi.4636