Klebsiella pneumoniae Necrotizing Fasciitis Associated with Diabetes and Liver Cirrhosis

Sir —We read with interest the two articles in Clinical Infectious Diseases on the association of necrotizing fasciitis and Klebsiella pneumoniae liver abscess by Hu et al. [ 1 ] and Dylewski and Dylewski [ 2 ]. Although K. pneumoniae is a common co-pathogen in patients with polymicrobial necrotizing fasciitis, the bacterium is rarely the sole cause of this serous soft tissue infection [ 3 ]. As was pointed out by Hu et al. [ 1 ], all 4 patients who had liver abscess and fasciitis also had diabetes. Therefore, an awareness of the spectrum of underlying diseases in association with monomicrobial klebsiella fasciitis is important. We describe a case of K. pneumoniae necrotizing fasciitis and spontaneous bacterial peritonitis in a patient with diabetes and cirrhosis. A 52-year-old man with diabetes and hepatitis B-related liver cirrhosis (Pudge-Child grade C) was admitted for evaluation of fever, and abdominal pain and distension. Physical examination revealed stigmata of chronic liver disease, ascites, and mild diffuse abdominal tenderness. There was no evidence of infection elsewhere. Abdominal centesis on the day of admission was unsuccessful. Ultrasonography of the hepatobiliary system revealed no evidence of liver abscess or biliary infection. Blood culture was obtained and he was given empirical treatment with cefoperazone/sulbactam for presumed spontaneous bacterial peritonitis. Two days later, blood culture yielded K. pneumoniae that was susceptible to cefoperazone/sulbactam, amoxicillin/clavulanate, and ofloxacin. Screening for production of extended-spectrum β-lactamase was negative. Culture of ascitic fluid obtained on day 6 was negative, but there was an increased polymorphonuclear leukocyte (PML) count of 129 × 10 6 /L, a very low protein level of 5 g/L, and a low pH of 7. The patient's condition improved over the next few days and the antibiotic was continued for a total of 10 days.