Introduction: Klebsiella pneumoniae is a well-described etiology of pyogenic liver abscess (PLA) in patients from Southeast Asia, but rarely outside of that region. We present a rare case of Klebsiella PLA in Eastern Long Island in a patient with no travel history to Southeast Asia.

Case Presentation: A 71-year-old Puerto Rican male with PMH diabetes, hepatitis C s/p treatment presented with dull, non-radiating right lower quadrant pain associated with non-bloody non-bilious vomiting and intermittent fevers for 2 weeks. He denied other previous gastric or hepatobiliary disease or malignancy, abdominal trauma/surgeries, alcohol use, IV drug use, history of pancreatitis or liver transplant, PPI use, or any travel history in the last 15 years. On examination, T 102.8°F, BP 126/86, HR 96, RR 27, SpO2 99% on RA; he had tenderness in the right lower quadrant. Labs showed normal WBC and hepatic function, and mildly elevated alkaline phosphatase at 142. CT abdomen/pelvis with oral and IV contrast showed a liver mass (Figure 1). Subsequent MRI abdomen with and without IV contrast (Figure 2) demonstrated a 6.1 x 6.9 x 6.9 cm posterior right hepatic lobe abscess. He was admitted for sepsis secondary to liver abscess and started on broad-spectrum antibiotics. The abscess was drained and fluid culture subsequently grew Klebsiella pneumoniae. The patient improved clinically during the remainder of the hospitalization and was discharged on four weeks of oral levofloxacin.

Discussion: Pyogenic liver abscesses (PLA) are pus-filled masses that can develop after hematogenous spread from an intraabdominal infection, bacteremia, or nearby liver injury. The incidence of pyogenic liver abscess is about 2.3 cases per 100,000 people and has been well-described in Southeast Asia – especially in Taiwan. Klebsiella pneumoniae PLA has been reported in Taiwan since the 1980’s with more than 900 cases identified, as compared to only 50 cases in Western countries from the 1990’s to early 2000s. In another extensive literature review, only 93 cases were found in the United States from 1949 to 2016. 80% of PLA cases found Klebsiella pneumoniae as the predominant bacteria, as compared to non-Eastern Asian countries, where E. coli and Streptococcus species predominate. Risk factors include diabetes, history of hepatobiliary infection or colorectal cancer, abdominal trauma or surgeries. Clinical features include fever, right upper abdominal, nausea and vomiting. Labs may show leukocytosis, hyperbilirubinemia, elevated ALP/ AST. MRI with IV contrast is the most sensitive study. Treatment involves drainage and antibiotic therapy, with good prognosis.

Conclusion: Clinicians should keep rare etiologies in mind for patients who present with liver abscesses.