Severe disseminated infection by hypermucoviscous Klebsiella pneumoniae successfully treated by intensive therapy with continuous hemodiafiltration using AN69ST: A case report and review of the literature.

Klebsiella pneumoniae (Kpn) is one of the most common gram-negative bacilli causing lung, urinary tract, and biliary tract infections. However, as a distinct entity from classic Kpn, hypervirulent Kpn causing liver abscess, endophthalmitis, and lung abscess with poor prognoses has been reported mainly in East and Southeast Asia since the mid-1980s. Although the definition of hypervirulent Kpn is unclear, the hypermucoviscosity of Kpn is considered an important feature of hypervirulence. We present a case of emphysematous pyelonephritis accompanied by septic shock and acute kidney injury caused by hypermucoviscous Kpn infection that was successfully treated by intensive treatment. A 70-year-old woman with type 2 diabetes mellitus was diagnosed with emphysematous pyelonephritis, and string test-positive Kpn was detected in blood and urine cultures and percutaneous catheter drainage fluid from the renal pelvis. The patient was treated with intensive therapies including antibiotics, ventilator management, and continuous hemodiafiltration (CHDF) using AN69ST, which can absorb cytokines. During the course of treatment, the infection was complicated by pyogenic spondylitis, which was cured by antimicrobial therapy, and the patient was transferred to another hospital for rehabilitation on day 119 after admission. Hypermucoviscous Kpn infection often has a severe course, and it is important to initiate multidisciplinary treatment at an early stage, including rifampicin, which is expected to inhibit the viscosity of hypermucoviscous Kpn. In the current case, immediate CHDF using AN69ST was also considered a life-saving treatment because it improved both volume overload and neutrophil-activated hypercytokinemia.

Coinfection with SARS-CoV-2 and Cytomegalovirus in a Patient with Mild COVID-19.

Persistent fever due to coronavirus disease 2019 (COVID-19) is a considerable issue for patients and physicians that requires a broad differential diagnosis and evaluation of complications. Coinfections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and various respiratory viruses have also been reported. In severe cases of COVID-19, cytomegalovirus (CMV) reactivation or CMV coinfection with SARS-CoV-2 has been reported in association with critical illnesses and immunosuppressive therapy; however, in mild COVID-19 cases, CMV coinfection with SARS-CoV-2 has been reported only in severely immunocompromised patients, and its incidence and clinical importance remain unclear. Herein, we report a rare case of coinfection with SARS-CoV-2 and CMV in a patient with mild COVID-19 and untreated diabetes mellitus, which led to persistent fever for approximately 4 weeks. CMV coinfection should be considered in patients with COVID-19 who exhibit persistent fever.

Rapidly-Progressing Pyomyositis After Chest Contusion in a Patient With Well-Controlled Diabetes Mellitus.

Pyomyositis is an uncommon acute bacterial infection of the skeletal muscle. It is sometimes referred to as "tropical pyomyositis" because it has been primarily reported as an endemic disease in tropical regions. In temperate climates, it is mainly diagnosed in immunocompromised persons, such as those with human immunodeficiency virus infection, malignancy, diabetes, and various other medical conditions. Early diagnosis and appropriate antimicrobial therapy for pyomyositis are important, however, it is often missed in its early stage. Herein, we report the case of a patient with obesity and well-controlled diabetes in whom rapid onset pyomyositis developed in only 2 days after chest contusion and induced bacteremia in its early stage. He was successfully treated by antimicrobials without any drainage or surgical intervention. Even in patients with well-controlled diabetes or in healthy persons, pyomyositis should be considered for patients who present with fever and muscle swelling and pain, especially when they have obesity and a history of blunt trauma. It should also be noted that pyomyositis, mimicking muscle contusion or hematoma can appear very early after blunt muscle trauma. Prompt diagnosis and antimicrobial treatment for pyomyositis can lead to a favorable outcome, without surgical drainage.

A case of emphysematous pyelonephritis caused by the hypermucoviscosity phenotype of Klebsiella pneumoniae.

A 70-year-old woman presented to our hospital with 38.2 °C fever. She was diagnosed with high-risk emphysematous pyelonephritis caused by string test-positive Klebsiella pneumoniae and treated with multidisciplinary therapy. The patient developed pyogenic spondylitis during the course of the disease. This is the first reported case of emphysematous pyelonephritis caused by the hypermucoviscosity phenotype of K. pneumoniae and the second reported case of pyogenic spondylitis. The hypermucoviscosity phenotype of K. pneumoniae should be considered as an etiologic agent of emphysematous pyelonephritis.