Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 25e26

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Journal of Orthopaedics, Trauma and Rehabilitation

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Case Report

Klebsiella pneumoniae Causing Necrotizing Fasciitis in a Patient With Thalassaemia Major

Kwan Kenny*, Fung Boris, Ip Wing-Yuk
Division of Hand Surgery, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong

a r t i c l e i n f o
Article history: Accepted February 2010 Keywords: Klebsiella pneumonia necrotizing fasciitis thalassaemia

a b s t r a c t
We present a case of Klebsiella pneumoniae necrotizing fasciitis in a patient with thalassaemia major. Klebsiella sp. is known to cause severe infections in patients with thalassaemia, with high mortality rates.

Case Report A 26-year-old man with a history of diabetes mellitus, beta thalassaemia major (Cooleys anaemia), and transfusion-related iron-overload cardiomyopathy and atrial brillation, was admitted to our hospital with progressive left forearm tenderness after insertion of an intravenous cannula, which was then promptly removed. Within 12 hours after admission, he developed a fever and intense pain of forearm. Examination showed minimal swelling, no erythema, no crepitus, and no neurovascular decit. Laboratory ndings were as follows: haemoglobin, 9.9 g/dL; white cell count, 4.5 109/L; platelet count, 156 109/L; C-reactive protein, 10.1 mg/dL; eyrthrocyte sedimentation rate, 80 mm/hr; and glucose, 24 mmol/L. A computed tomography scan of the forearm demonstrated swollen exor carpi ulnaris but no abnormal gaseous density. Aspiration at the site of maximal tenderness on the anterior aspect of the forearm yielded serous uid, which subsequently revealed gram-negative rods. Parenteral antibiotics, including ciprooxacin, and subsequently, meropenem were administered. Emergency surgery revealed necrotizing fasciitis of the forearm from the cubital fossa to the carpal tunnel (Figure 1A). This was conrmed subsequently on histological examination of the tissue specimen. Intraoperative cultures resulted in pure growth of Klebsiella pneumoniae susceptible to ceftriaxone, gentamicin, and piperacillin/tazobactam.

The antibiotic regimen was converted to intravenous tazocin. Fortyeight hours later, he developed a swelling in his left ank, and aspiration revealed frank pus. He underwent an emergency incision and drainage, which revealed subcutaneous necrotic tissue although cultures did not yield any growth. He underwent six further surgical procedures for surgical debridement and wound coverage using partial-thickness skin graft. He was discharged after 66 days in our hospital, and the wound had completely healed (Figure 1B). Antimicrobial treatment was administered for a total of 48 days. Discussion Monomicrobial (Type II) necrotizing fasciitis is commonly caused by Group A streptococci, with more than 25% of cases caused by Streptococcus pyogenes. K pneumoniae is a common co-pathogen in polymicrobial (Type I) disease, but it is very rarely the sole organism causing this infection.1 To our knowledge, only 15 cases have been reported in the literature. With the exception of one case occurring in Turkey2 and one in Canada,3 all the remaining cases occurred in Asian countries, with 11 cases reported in Singapore, Hong Kong, Taiwan, Japan, and Malaysia; one in a native Indian who had recently travelled to Singapore; and one in a Cambodian man treated in North America.4e10 Twelve of the 15 cases were associated with diabetes mellitus or chronic liver disease. The clinical features of Klebsiella sp. necrotizing fasciitis are similar to those caused by other organisms, but it tends to occur as a result of haematogenous seeding rather than direct innoculation,

* Corresponding author. E-mail: [email protected].

2210-4917/$ e see front matter Copyright 2011, The Hong Kong Orthopaedic Association and Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. All rights reserved. doi:10.1016/j.jotr.2010.11.003

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K. Kwan et al. / Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 25e26

Pseudomonas aeruginosa, are so impaired in iron acquisition ability that their virulence is increased in the presence of excess iron. Interestingly, Y enterocolitica predominantly affects thalassaemic patients in Western countries, whereas Klebsiella sp. infections have only been reported from Asia.12 High rates of morbidity and mortality are associated with cases of Klebsiella sp. infections. Oral chelating agents have also been demonstrated recently to enhance the growth of Klebsiella. Both diabetes and thalassaemia predisposed our patient to severe bacterial infection. It is not possible to determine if our patient had contracted the infection by direct inoculation from the intravenous cannula. The propensity for Klebsiella sp. to infect hosts with iron-loading conditions resulted in this rare but serious case of monomicrobial K pneumoniae necrotizing fasciitis. Early recognition and prompt radical surgical debridement resulted in successful eradication of the infection.

Figure 1. (A) Intra-operative ndings of extensive necrotizing fasciitis spanning the volar aspect of the forearm. (B) Complete recovery with skin graft well healed on discharge.

References
1. Chapnick EK, Abter EI. Necrotizing soft-tissue infections. Infect Dis Clin North Am 1996;10:835e55. 2. Ozkan H, Kumtepe S, Turan A, et al. Perianal necrotizing fasciitis in a neonate. Indian J Pediatr 1997;64:116e8. 3. Greer-Bayramoglu R, Matic DB, Kiaii B, et al. Klebsiella oxytoca necrotizing fasciitis after orthotopic heart transplant. J Heart Lung Transplant 2008;27: 1265e7. 4. Oishi H, Kagawa Y, Mitsumizo S, et al. A fatal case of necrotizing fasciitis due to bacterial translocation of Klebsiella oxytoca. J Infect Chemother 2008;14:62e5. 5. Kohler JE, Hutchens MP, Sadow PM, et al. Klebsiella pneumoniae necrotizing fasciitis and septic arthritis: an appearance in the Western hemisphere. Surg Infect 2007;8:227e32. 6. Mazita A, Abdullah A, Primuharsa SH. Cervical necrotizing fasciitis due to klebsiella. Med J Malaysia 2005;60:657e9. 7. Hu BS, Lau YJ, Shi ZY, et al. Necrotizing fasciitis associated with Klebsiella pneumoniae with liver abscess. Clin Infect Dis 1999;29:1360e1. 8. Dylewski JS, Dylewski I. Necrotizing fasciitis with Klebsiella liver abscess. Clin Infect Dis 1998;27:1561e2. 9. Ho PL, Tang WM, Yuen KY. Klebsiella pneumoniae necrotizing fasciitis associated with diabetes and liver cirrhosis. Clin Infect Dis 2000;30:989e90. 10. Wang JH, Liu YC, Lee SS-J, et al. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998;26:1434e8. 11. Fung CP, Hu BS, Chang FY, et al. A 5-year study of the seroepidemiology of Klebsiella pneumoniae: high prevalence of capsular serotype K1 in Taiwan and implication for vaccine efcacy. J Infect Dis 2000;181:2075e9. 12. Vento S, Cainelli F, Cesario F. Infections and thalassaemia. Lancet Infect Dis 2006;6:226e33.

with rapid spread causing multifocal infection. The pathogenicity of different virulent strains of K pneumoniae is determined by their polysaccharide envelope. It has been recognised that the most virulent K1 serotype is more prevalent in the East.11 They tend to cause disseminated infection with multiorgan involvement. A high index of suspicion is required in all patients with soft tissue infections, but necrotizing fasciitis needs to be excluded actively, particularly if Klebsiella sepsis is established in this group of patients. Thalassaemic patients have underlying immune abnormalities and immune deciencies caused by splenectomy and multiple blood transfusions. They are often in a state of iron overload, both from the excessive iron absorption normally present in such cases and from regular blood transfusions. Such patients are often on oral chelating agents to reduce their iron load. Iron is an essential growth factor for bacteria, and many common gram-negative bacteria secrete high-afnity Fe chelators called siderophores. Some pathogens, such as Yersinia enterocolitica, Klebsiella sp., and