A 58-year-old woman was admitted
because of intermittent high fever with chills for 5 days.
She was a housewife without any
known systemic diseases, such as hypertension, diabetes, liver
or renal diseases. She did not have the habit of smoking or
drinking and no travel history recently. Polydipsia and
polyuria developed since 2 months ago. Fever associated with
chills, general malaise and abdominal fullness were noticed
since 5 days ago. Her body temperature had been elevated up to
39.6° C. No severe abdominal pain, cough, dysuria or diarrhea
was complained. Although high fever could subside after
medical treatment from outside clinic, but it recurred several
hours later. So she came to ER for help.
At ER, her consciousness was clear
and oriented. The temperature was 38° C, pulse rate 123/min,
respiratory rate 24/min and blood pressure 100/62 mmHg. The
conjunctivae were not pale or injected and sclera was
anicteric. Pupils were isocoric and throat was not injected.
The neck was supple without lymphadenopathy. The jugular veins
were not distended. Respiratory sounds were symmetric and
clear. Rapid heart beat without audible murmurs were observed.
Abdomen was soft, but mildly distended. Liver margin was
palpable at 2 cm below the right costal margin. No tenderness
was detected. Bowel sounds were normoactive. There was
knocking pain at the right flank. The extremities were freely
movable without pitting edema or ecchymosis.
Laboratory Data:
1. CBC and differential count:
WBC /μl |
RBC M/μl |
Hb g/dl |
Plt K/μl |
Hct % |
MCV fL |
Band % |
Neu % |
Baso % |
Eos % |
Mon % |
Lym % |
9530 |
3.84 |
11.1 |
195 |
34.0 |
87.3 |
14 |
78 |
0 |
0 |
3 |
5 |
2.
Biochemistry:
A/G g/dl |
BilT/D mg/dl |
ALP U/L |
AST U/L |
ALT U/L |
r-GT U/L |
BUN mg/dl |
Cre mg/dl |
Na mM |
K mM |
Cl mM |
2.4/3.5 |
1.5/1.0 |
495 |
22 |
30 |
335 |
18.6 |
1.1 |
134 |
3.4 |
102 |
Ca mM/dl |
P mg/dl |
Mg mM/dl |
Glu mg/dl |
LDH U/L |
TG mg/dl |
T-CHO mg/dl |
UA mg/dl |
1.87 |
3.4 |
0.82 |
335 |
392 |
75 |
123 |
6.8 |
3.
Urinalysis:
Outlook |
PH |
Pro |
Sugar |
KB |
OB |
Bil |
Urobil |
RBC |
WBC |
Epi |
Y,C |
5.0 |
- |
3+ |
- |
2+ |
1+ |
1.0 |
2-4 |
1-2 |
0-1 |
4. PT: 16.6/12.4 sec.; PTT: 56.2/39 sec.
5. Arterial blood gas: (O2 nasal cannula 3l/min)
PH |
PaCO2 |
PaO2 |
BE |
HCO3 |
SaO2 |
7.438 |
26.3 |
92.0 |
-6.8 |
15.1 |
98.1% |
6. Stool
occult
blood
(-)
7. HbA1c: 12.6%
8. Blood culture: Klebsiella pneumoniae
9. IHA test: 1: 8 (-)
10. Abdominal sonography
Course and Treatment:
Although no leukocytosis was
seen, there was left shifting distribution of white blood
cells. Empirical antibiotics with cefazolin 1gm IV q8h and
gentamicin 160mg IV drip qd were prescribed for possible
infection after blood culture. Insulin treatment was also
started for poor-controlled hyperglycemia and she was
admitted. Abdominal sonography revealed a hypoechoic lesion,
measuring 6.8 x 5.9 cm, at right lateral superior segment of
the liver. Liver abscess was impressed. On the third day after
admission, fever still persisted and sudden onset of right eye
pain with injected conjunctivae developed. Progressively
blurred vision was told thereafter. Blood culture disclosed
Klebsiella pneumoniae and septic endophthalmitis was favored
for her visual loss. Antibiotic was shifted to ceftriaxone 2gm
IV q12h. Ultrasound-guided drainage of liver abscess was
performed and pus-like fluid was withdrawn. The fever was
controlled later, but the visual acuity didn't improve much.
Subconjunctival injection of ceftazidime and amikacin were
done and vitrectomy was performed later. The antibiotic was
continued for 4 weeks. Hyperglycemia was controlled by oral
hypoglycemic agent. However her visual acuity was still poor
with only capability of counting fingers at 15 cm distance.
病例分析
本病例為一位中年女性發燒及上腹部不適多日,經多次就醫後症狀仍未改善,經過胸部X光及尿液檢查排除常見的呼吸道及泌尿道感染,在進一步作腹部超音波檢查,後來診斷其本身有糖尿病,發生了肝膿瘍併有Klebsiella
pneumoniae敗血症,期間更併發眼內炎,造成視力的不可逆的傷害。糖尿病的病人,若是血糖控制不良, 人體的白血球功能便受到影響,特別是吞噬殺菌的能力會降低,因此糖尿病的病人,較常見到細菌的感染,更有一些特殊的嚴重感染疾病好發在糖尿病病人身上,如Emphysematous pyelonephritis、Emphysematous
cholecystitis、Malignant otitis externa、Rhinocerebral
mucomycosis以及本例的Klebsiella pneumoniae liver abscess
with
endophthalmitis等,Klebsiella
pneumoniae造成肝膿瘍,甚至進而演變成眼內炎的病例,在台灣地區比世界其他地區來得多,至今仍未有確切的解釋原因,因為致病的菌種並未發現有所不同,更可惜的是目前仍不能預測何種病人較易發生眼內炎,而及早實施眼內抗生素治療,以補強一般抗生素在眼球內的不足藥效,否則一旦症狀出現後病人的視力都會受到不可逆的傷害。
此外肝膿瘍的產生致病菌種多來自腸胃道、膽道的感染,另有少數是源自血行性感染、臨近器官的感染或是外傷穿透引起,菌種以腸內菌如E.
coli、Klebsiella、Enterococcus、Anaerobic
pathogen及Amoeba,隨著癌症及血液腫瘤作化學治療病人的增多,黴菌或是結核菌的肝膿瘍的病例也有增加的現象,另外也要注意是否化膿性肝膿瘍為續發自肝臟腫瘤。
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