CASE 13416 Published on 02.05.2016

Endopthalmitis, brain abscesses probably seconday to metastatic renal abscess secondary to virulent Klebsiella species



Case Type

Clinical Cases


Suman Karki, M.D.

Manila Med Medical Center Manila;
U.N Ave Taft Corner
1000 Manila, Philippines;

73 years, female

Area of Interest Eyes, Neuroradiology brain, Abdomen ; Imaging Technique Image manipulation / Reconstruction, CT, Ultrasound
Clinical History
This is a case of a 73-year-old female patient with long-standing history of hypertension, diabetes on maintenance medication admitted due to altered sensorium. The patient also has a history of yellowish eye discharge, blurring of vision and undocumented fever, self-medicated without improvement.
Imaging Findings
CT scan of the head with and without iv contrast shows multiple ring enhancing lesions with central low attenuation within the brain parenchyma. Findings are consistent with brain abscess. There is also enhanced thickened sclera on the left eye with possibility of an adjacent abscess and/or inflammation.

Ultrasound of the whole abdomen shows 3.8 x 3.0 x 3.9 cm hypoechoic collation with internal echoes at the mid portion of the left kidney displacing and distorting adjacent renal parenchyma suggesting a subcapsular location. There is also a hypoechoic collection noted at the parenchyma of the upper pole. This findings are consistent with subcapsular and renal abscesses.
On examination the patient was drowsy, there was marked conjunctival injection with membranous formation and yellow discharge on the left eye. Hypopyon was also visualized at the anterior chamber. CBC was done which showed leukocytosis with neutrophila, urinalysis revealed UTI. Culture of the exudate from the eye, and viterous tap showed colonies of Klebsiella Sp. Ophthalmology consultation was done and diagnosis of endogenous endopthalmitis was made.

Endopthalmitis is an intraocular inflammatory process that may result from exogenous (primary, postoperative, or post traumatic infection) or endogenous cause. Endogenous opthalmitis is rare, accounting for 2 to 8% of all causes of endopthalmitis, and results from haematogeneous spread [2]. Staphylococcus is the most common cause of bacterial endopthalmitis in the West, while Klebsiella pneumonia is the most common in the East. Most of the endogeneous endopthalmitis in the East arise from a Klebsiella liver abscess, but there was a reported case of Klebsiella renal abscess with metastatic lesion to the brain, eyes and lungs [1].

Klebsiella Sp. is a highly virulent gram negative bacteria of the enterobacteriaceae family that causes a nosocomial infection. It has a high tendency to infect immunocompromised patients. Patients with diabetes are known to have impaired immune response and are at higher risk for developing Klebsiella infection with multi-organ involvement.

In our case we focus on Klebsiella Sp. with multi-organ septic involvement especially (brain and eye) in the form of brain abscess and endopthalmitis with primary focus involving the renal abscess. There are several risk factors for development of renal abscess which include urolithiasis, recurrent UTI, history of urologic surgery, trauma and diabetes.

Therefore early identification of an infection caused by this virulent organism and organ involvement is important for treatment and better prognosis. So it is always advisable to do an abdominal scan (Ultrasound/CT) if the initial diagnosis of endopthalmitis was made, especially in a diabetic patient.
Differential Diagnosis List
Endogenous endopthalmitis, brain abscess probably secondary to metastatic renal abscess secondary to Klebsiella species
Final Diagnosis
Endogenous endopthalmitis, brain abscess probably secondary to metastatic renal abscess secondary to Klebsiella species
Case information
DOI: 10.1594/EURORAD/CASE.13416
ISSN: 1563-4086