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. © 2011.

我們敍述一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎的病例。克雷白氏菌屬已知會對地中海型貧血的病人造成嚴重的感染並有很高的死亡率。published_or_final_versio

Fung, B

IP, WY

Kwan, KYH

Journal of Orthopaedics Trauma and Rehabilitation

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TitleKlebsiella pneumoniae causing necrotizing fasciitis in a patientwith thalassaemia major; 一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎Author(s) Kwan, KYH; Fung, B; IP, WYCitation Journal of Orthopaedics, Trauma and Rehabilitation, 2011, v. 15n. 1, p. 25-26Issued Date 2011URL http://hdl.handle.net/10722/222420Rights This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.lable at ScienceDirectJournal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 25e26Contents lists avaiJournal of Orthopaedics, Trauma and RehabilitationJournal homepages: www.e- jotr .com & www.ejotr .orgCase ReportKlebsiella pneumoniae Causing Necrotizing Fasciitis in a PatientWith Thalassaemia Major一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎Kwan Kenny*, Fung Boris, Ip Wing-YukDivision of Hand Surgery, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Konga r t i c l e i n f oArticle history:Accepted February 2010Keywords:Klebsiella pneumonianecrotizing fasciitisthalassaemia* Corresponding author. E-mail: k.kwan@doctors.or2210-4917/$ e see front matter Copyright  2011, The Hong Kodoi:10.1016/j.jotr.2010.11.003a b s t r a c tWe 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.中 文 摘 要我們敍述一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎的病例。克雷白氏菌屬已知會對地中海型貧血的病人造成嚴重的感染並有很高的死亡率。Case ReportA 26-year-old man with a history of diabetes mellitus, betathalassaemia major (Cooley’s anaemia), and transfusion-relatediron-overload cardiomyopathy and atrial ﬁbrillation, was admittedto our hospital with progressive left forearm tenderness afterinsertion of an intravenous cannula, which was then promptlyremoved. Within 12 hours after admission, he developed a feverand intense pain of forearm. Examination showed minimalswelling, no erythema, no crepitus, and no neurovascular deﬁcit.Laboratory ﬁndings were as follows: haemoglobin, 9.9 g/dL; whitecell count, 4.5109/L; platelet count, 156109/L; C-reactiveprotein, 10.1 mg/dL; eyrthrocyte sedimentation rate, 80 mm/hr;and glucose, 24 mmol/L.A computed tomography scan of the forearm demonstratedswollen ﬂexor carpi ulnaris but no abnormal gaseous density.Aspirationat the siteofmaximal tendernesson theanterioraspectofthe forearm yielded serous ﬂuid, which subsequently revealedgram-negative rods. Parenteral antibiotics, including ciproﬂoxacin,and subsequently, meropenem were administered. Emergencysurgery revealed necrotizing fasciitis of the forearm from the cubitalfossa to the carpal tunnel (Figure 1A). This was conﬁrmed subse-quently on histological examination of the tissue specimen. Intra-operative cultures resulted in pure growth of Klebsiella pneumoniaesusceptible to ceftriaxone, gentamicin, and piperacillin/tazobactam.g.uk.ng Orthopaedic Association and Hong KoThe antibiotic regimenwas converted to intravenous tazocin. Forty-eight hours later, he developed a swelling in his left ﬂank, andaspiration revealed frank pus. He underwent an emergency incisionanddrainage,which revealed subcutaneousnecrotic tissuealthoughcultures did not yield any growth.He underwent six further surgical procedures for surgicaldebridement and wound coverage using partial-thickness skingraft. He was discharged after 66 days in our hospital, and thewound had completely healed (Figure 1B). Antimicrobial treatmentwas administered for a total of 48 days.DiscussionMonomicrobial (Type II) necrotizing fasciitis is commonlycausedby Group A streptococci, with more than 25% of cases caused byStreptococcus pyogenes. K pneumoniae is a common co-pathogen inpolymicrobial (Type I) disease, but it is very rarely the sole organismcausing this infection.1 To our knowledge, only 15 cases have beenreported in the literature. With the exception of one case occurringin Turkey2 and one in Canada,3 all the remaining cases occurred inAsian countries, with 11 cases reported in Singapore, Hong Kong,Taiwan, Japan, andMalaysia; one in a native Indianwhohad recentlytravelled to Singapore; andone in aCambodianman treated inNorthAmerica.4e10 Twelve of the 15 cases were associated with diabetesmellitus or chronic liver disease.The clinical features of Klebsiella sp. necrotizing fasciitis aresimilar to those caused by other organisms, but it tends to occur asa result of haematogenous seeding rather than direct innoculation,ng College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. All rights reserved.Figure 1. (A) Intra-operative ﬁndings of extensive necrotizing fasciitis spanning thevolar aspect of the forearm. (B) Complete recovery with skin graft well healed ondischarge.K. Kwan et al. / Journal of Orthopaedics, Trauma and Rehabilitation 15 (2011) 25e2626with rapid spread causingmultifocal infection. The pathogenicity ofdifferent virulent strains of K pneumoniae is determined by theirpolysaccharide envelope. It has been recognised that the mostvirulent K1 serotype is more prevalent in the East.11 They tend tocause disseminated infection with multiorgan involvement. A highindex of suspicion is required in all patients with soft tissueinfections, but necrotizing fasciitis needs to be excluded actively,particularly if Klebsiella sepsis is established in this group ofpatients.Thalassaemic patients have underlying immune abnormalitiesand immune deﬁciencies caused by splenectomy and multipleblood transfusions. They are often in a state of iron overload, bothfrom the excessive iron absorption normally present in such casesand from regular blood transfusions. Such patients are often on oralchelating agents to reduce their iron load. Iron is an essentialgrowth factor for bacteria, and many common gram-negativebacteria secrete high-afﬁnity Fe chelators called siderophores.Some pathogens, such as Yersinia enterocolitica, Klebsiella sp., andPseudomonas aeruginosa, are so impaired in iron acquisition abilitythat their virulence is increased in the presence of excess iron.Interestingly, Y enterocolitica predominantly affects thalassaemicpatients in Western countries, whereas Klebsiella sp. infectionshave only been reported from Asia.12 High rates of morbidity andmortality are associated with cases of Klebsiella sp. infections. Oralchelating agents have also been demonstrated recently to enhancethe growth of Klebsiella.Both diabetes and thalassaemia predisposed our patient tosevere bacterial infection. It is not possible to determine if ourpatient had contracted the infection by direct inoculation from theintravenous cannula. The propensity for Klebsiella sp. to infect hostswith iron-loading conditions resulted in this rare but serious case ofmonomicrobial K pneumoniae necrotizing fasciitis. Early recogni-tion and prompt radical surgical debridement resulted in successfuleradication of the infection.References1. Chapnick EK, Abter EI. Necrotizing soft-tissue infections. Infect Dis Clin NorthAm 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 necrotizingfasciitis 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 tobacterial translocation of Klebsiella oxytoca. J Infect Chemother 2008;14:62e5.5. Kohler JE, Hutchens MP, Sadow PM, et al. Klebsiella pneumoniae necrotizingfasciitis and septic arthritis: an appearance in the Western hemisphere. SurgInfect 2007;8:227e32.6. Mazita A, Abdullah A, Primuharsa SH. Cervical necrotizing fasciitis due toklebsiella. Med J Malaysia 2005;60:657e9.7. Hu BS, Lau YJ, Shi ZY, et al. Necrotizing fasciitis associated with Klebsiellapneumoniae with liver abscess. Clin Infect Dis 1999;29:1360e1.8. Dylewski JS, Dylewski I. Necrotizing fasciitis with Klebsiella liver abscess. ClinInfect Dis 1998;27:1561e2.9. Ho PL, Tang WM, Yuen KY. Klebsiella pneumoniae necrotizing fasciitis associ-ated 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 pneu-moniae in Taiwan. Clin Infect Dis 1998;26:1434e8.11. Fung CP, Hu BS, Chang FY, et al. A 5-year study of the seroepidemiology ofKlebsiella pneumoniae: high prevalence of capsular serotype K1 in Taiwan andimplication for vaccine efﬁcacy. J Infect Dis 2000;181:2075e9.12. Vento S, Cainelli F, Cesario F. Infections and thalassaemia. Lancet Infect Dis2006;6:226e33.

一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎

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