Journal of Microbiology, Immunology and Infection (2016) 49, 621e622

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CORRESPONDENCE

A case of liver abscess caused by

tigecycline-nonsusceptible Klebsiella
pneumoniae

Dear Editor, administered. Cultures from both blood and liver abscess
yielded K. pneumoniae, which was resistant to ampicillin,
Klebsiella pneumoniae has emerged as the major cause of
cefuroxime, and cefmetazole, as established by the VITEK 2
liver abscesses in Asian countries, resulting in a high eco- system. According to the United States Food and Drug
nomic burden in Taiwan.1 Capsular Type K1 and K2, rmpA Administration criteria (&2.0 mg/L, susceptible; 4.0 mg/L,
gene, and hypermucoviscosity are well-known virulence intermediate; S8.0 mg/L, resistant), the isolate exhibited
factors in the invasive K. pneumoniae strains.2 K. pneu- intermediate resistance to tigecycline (minimum inhibitory
moniae strains causing liver abscess usually show charac- concentration Z 4 mg/L), as determined by the E test (
teristic antibiotic resistance to ampicillin only, but remain bioMerieux, Marcy lEtoile, France). The patient received a
susceptible to other antibiotics including all cephalosporins 4-week course of ceftriaxone as the definitive antimicrobial
and aminoglycosides. Multidrug-resistant isolates have therapy, and abdominal ultrasonography showed resolution
rarely been reported as the cause of primary liver ab- of the liver abscess thereafter. This K. pneumoniae strain
scesses.3 Tigecycline is regarded as one of the few regimens
for the treatment of multidrug-resistant pathogens.
Although clinical studies regarding tigecycline-resistant K.
pneumoniae are still limited,4 tigecycline resistance in K.
pneumonia was often found to be due to overexpression of
AcrAB efflux pump and its positive regulator RamA.5 We
firstly identified a case of community-acquired liver abscess
caused by tigecycline-nonsusceptible K. pneumoniae at
Taipei Veterans General Hospital in Taiwan. Virulence fac-
tors and mechanisms for drug resistance of this K. pneu-
moniae strain were investigated as well.
In May 2015, a 64-year-old woman with a medical history
of hypertension and poor-controlled diabetes mellitus
(hemoglobin A1c Z 9.5%) was admitted because of epigas-
tric pain and fever. Initial laboratory examination revealed
leukocytosis (white blood cell count: 16,900/mL) with
neutrophilia (segment: 92%), hyperglycemia (glucose:
673 mg/dL), and elevated levels of C-reactive protein
(28.33 mg/dL), alanine aminotransferase (183 U/L), and
alkaline phosphatase (210 U/L). A computed tomography
scan of the abdomen (Figure 1) showed a huge gas-forming
abscess in liver (Segment 4), 10.0 cm
9.7 cm
8.5 cm in Figure 1. Abdominal CT image as a diagnostic tool of liver
size, with intraperitoneal free air and ascites in the pelvis. abscess. This contrast CT of the abdomen revealed a huge gas-
The patient underwent emergent laparoscopic drainage of forming liver abscess (arrow), 10.0 cm
9.7 cm
8.5 cm in
the abscess, and intravenous imipenem was empirically size, with intraperitoneal free air. CT Z computed tomography.

http://dx.doi.org/10.1016/j.jmii.2016.04.010
1684-1182/Copyright 2016, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
622
was hypermucoviscous, as shown by the formation of
mucoviscous strings when a loop passed through a colony. It
belonged to capsular genotype K2 and carried the rmpA. In
addition, real-time quantitative reverse transcription po-
lymerase chain reaction using primers acrB-F (50 -CAA-
TACGGAAGAGTTTGGCA-30 ), acrB-R (50 -CAGACGAACCTGG-
GAACC-30 ), ramA-F (50 -GCATCAACCGCTGCGTATT-30 ), and
ramA-R (50 -CGTTGCAGATGCCATTTCG-30 ) showed over-
expression of the efflux pump gene acrB (7.1  0.4-fold)
and its regulatory gene ramA (38.4  1.2-fold) relative to
the control strain KP 478 (tigecycline minimum inhibitory
concentration Z 0.25 mg/L).
The current case demonstrated a severe gas-forming
liver abscess caused by a K. pneumoniae strain with
capsular serotype K2 and nonsusceptibility to tigecycline. It
indicates that tigecycline nonsusceptibility can develop in a
virulent strain. The emergence of hypervirulent
tigecycline-resistant K. pneumoniae might result in severe
public health consequences. The relationship between
tigecycline resistance and virulence among K. pneumoniae
strains requires further investigation.
Conflicts of interest
All authors declare no conflicts of interest.
References
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characteristics and economic consequence of Klebsiella pneu-
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Clinical and microbiological characteristics of peritoneal
dialysis-related peritonitis caused by Klebsiella pneumoniae in
southern Taiwan. J Microbiol Immunol Infect 2015;48:276e83.
Correspondence
3. Hsueh PR, Wu JJ, Teng LJ, Chen YC, Yang PC, Ho SW, et al.
Primary liver abscess caused by one clone of Klebsiella pneu-
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Han-Sian Yang
Department of Education, Taipei Veterans General
Hospital, Taipei, Taiwan
Wen-Liang Fang
Division of General Surgery, Department of Surgery, Taipei
Veterans General Hospital, Taipei, Taiwan
School of Medicine, National Yang-Ming University, Taipei,
Taiwan
Yi-Tsung Lin*
School of Medicine, National Yang-Ming University, Taipei,
Taiwan
Division of Infectious Diseases, Department of Medicine,
Taipei Veterans General Hospital, Taipei, Taiwan
*Corresponding author. Division of Infectious Disease,
Department of Medicine, Taipei Veterans General Hospital,
Number 201, Section 2, Shih-Pai Road, Beitou District,
Taipei City 11217, Taiwan.
E-mail address: ytlin8@vghtpe.gov.tw (Y.-T. Lin)
12 January 2016
Available online 13 May 2016