Discussion
As we know from the basics of microbiology, Klebsiella pneumoniae is a gram-negative, facultative anaerobic, rod-shaped bacterium belonging to the Enterobacteriaceae genus. K. pneumoniae infections are usually hospital-acquired and occur in patients with impaired immunity. A unique exception to this is syndromes involving community-acquired primary liver abscesses which have been typically described in East Asian countries.1 We present a case of panophthalmitis and cerebellar abscess in association with a pyogenic liver abscess caused due to K. pneumoniae. Panophthalmitis differs from endophthalmitis due to inflammation extending to periocular tissue thereby involving all structures of the eyeball. A study on endogenous panophthalmitis described that 12 out of 18 patients with panophthalmitis had an infection caused by K. Pneumoniae, which was most commonly associated with liver abscesses.2Our case adds to the list with an addition that the central nervous system (CNS) complications can occur concurrently along with panophthalmitis.
A Taiwanese retrospective cohort study of 177 cases of K. pneumoniae pyogenic liver abscess identified genotype K1 as a possible significant risk factor for causing ocular and CNS complications.1 Although the K1 serotype may be an important risk factor, the K2 serotype might also carry the potential of invasive disease.3 Cases of K2 serotype causing invasive liver abscess have been reported and it is certainly possible to develop metastatic infections in such instances.4,5 Diabetes is a notable risk factor for metastatic infectious disease as evident in our case.6,7 Genotype identification of Klebsiella was not done in this particular case, which is one of the limitations in this report. A 20-year retrospective study regarding K. pneumoniae endophthalmitis in association with pyogenic liver abscess concluded that only 5 patients out of 144 had more than one infectious focus; making it extremely rare.8 The same study also concluded that pyogenic liver abscess-related endophthalmitis due to K. pneumoniae leads to poor visual outcomes.8The right lobe of the liver is the most common site of abscess formation possibly due to typical unequal portal venous distribution from superior and inferior mesenteric vein.9
Management involves early initiation of intravenous antibiotics along with surgical or percutaneous drainage of the liver abscess to reduce morbidity and mortality. Prognosis in terms of visual outcome ofK. Pneumoniae endophthalmitis is generally poor; prompt treatment is necessary. The patient may require evisceration or enucleation, but early vitrectomy may be useful in a select group of patients who do not respond to intravitreal antibiotics.7