Fatal community-acquired bloodstream infection caused by Klebsiella variicola:A

INTRODUCTION

()infections are known to be associated with high incidence and mortality.This microorganism causes outbreaks of nosocomial infections and even drug resistance,and can lead to infection in the community among health-care patients or people with underlying immunodeficiency[1].Based on genetic analysis,is divided into three phylogroups:(KpI),(KpII),and(KpIII)[2].KpI is the most frequent group encountered in the clinic,followed by KpIII and KpII[1,3].KpI is usually defined as classic(Ck)or hypervirulent(Hvkp)according to their invasiveness or virulence,while subspecies of(KpII and KpIII)usually present with higher virulence[1].Currently,approximately 20% of the human isolates assumed to beare in factor[1].However,since classical laboratory examinations cannot readily distinguish KpI from the KpII and KpIII phylogroups[4],the clinical hazards and importance of KpII and KpIII are often overlooked.

They had much to tell each other as they rode along, and at last the younger man exclaimed, O fool, to leave such a beautiful wife to go and fight a witch! She took me for her husband, and I did not say her nay32

CASE PRESENTATION

Chief complaints

A 52-year-old man presented with unexplained high fever,abdominal pain,and headache for 1 d.

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History of present illness

The patient was subsequently admitted to the intensive care unit with diarrhea and confusion.

History of past illness

Science and Technology Fund of Guizhou Provincial Health Commission,No.gzwjkj2019-1-067;and Doctor Foundation of Guizhou Provincial People's Hospital,No.GZSYBS[2019]04.

Personal and family history

The patient had no particular individual or family history.

Physical examination

Chest radiography showed the manifestations of an inflammatory response,while other imaging results showed no obvious abnormalities(Figures 1-3).

Laboratory examinations

Laboratory examinations revealed slightly deteriorated hepatorenal function and clotting function and increases in inflammatory parameters(Tables 1-3).Other laboratory biochemical tests proved negative for signs of viral and mycobacterial infections along with mycoplasma/chlamydia and biomarkers of autoimmune diseases(Table 4).Traditional bacterial culture of the patients’ blood sample showed bacterial infection with(Table 5).

Imaging examinations

Physical assessment revealed a body temperature of 40 ℃ but without other obvious abnormal signs.

It took place at the Biltmore Hotel, which, to my eight-year-old mind, was just about the fancies place to eat in all of Providence6. My grandmother, my mother, and I were having lunch after a morning spent shopping. I grandly ordered a salisbury steak, confident in the knowledge that beneath that fancy name was a good old hamburger with gravy7. When brought to the table, it was accompanied by a plate of peas. I do not like peas now. I did not like peas then. I have always hated peas. It is a complete mystery to me why anyone would voluntarily eat peas. I did not eat them at home. I did not eat them at restaurants. And I certainly was not about to eat them now. Eat your peas, my grandmother said.

FINAL DIAGNOSIS

Based on the patient’s symptoms and laboratory data,sepsis and septic shock were diagnosed according to the diagnostic criteria.

is a genus of Gram-negative bacterium within the Enterobacteriaceae family.It usually causes opportunistic nosocomial infections among hospitalized patients or outbreaks of community-acquired infections.mainly colonizes human gut but it has also been isolated from the skin surfaces such as hands and face,and can be isolated from various environmental sources including water,plants,and soil[1,5].The genus contains several subspecies that manifest varied clinical outcomes,even death,leading to significant concerns about the accurate and timely identification of thesubspecies involved together with a better understanding of the patient risk factors involved to reduce mortality risks[6].

TREATMENT

The initial treatment prescribed after the availability of the laboratory results involved a broad-spectrumregimen for bacterial and fungal infections(intravenous meropenem 1 g per 6 h + intravenous caspofungin 70 mg/initial dose).

OUTCOME AND FOLLOW-UP

Recent research has revealed that diabetes is a significant risk factor for hypervirulentinfection and for causing serious complications[7-9].In our patient’s case,a medical history of T2DM could have contributed to an underlying immunodeficiency that was responsible for the fatal systemic infection.Although bothandwere detected in the patients’ blood sample,may have played a more decisive role in the resulting outcome since treatment to targetfailed to improve the patient’s condition.Moreover,this is consistent with the notion thatis a frequent cause of bloodstream infections and higher mortality[3,4].

DISCUSSION

For that very reason, just before bedtime, Mother tip-toed quietly to Kelly’s room to lay out the little blue nightgown and turn down the bed. But she stopped in the doorway37, surprised. Someone had already been there. The nightgown was laid neatly across the bed and a small red race car rested next to it on the pillow.

The patient’s condition rapidly deteriorated within hours of admission with decreased blood pressureand reduced oxygen saturation.Life support therapies including mechanical ventilation and vasoactive drugs did not improve the patient’s condition.He suffered cardiac arrest on the second day of admission and was declared clinically dead after several rescue efforts.The PMseq-DNA Pro high throughput gene detection assay was initiated on the second day after admission with the results acquired 2 d later.This analysis revealed infection withand(Table 6).A bone marrow biopsy supported the findings of severe bacterial infection(Figure 4).

It is difficult to distinguishand its subspecies by classic bacterial culture methods.This may lead to misdiagnosis or delayed diagnosis and incorrect treatment[4].As shown in this case,was found in blood culture and although the clinical isolate was shown to be sensitive to the carbapenem class of antibiotics,the patient did not respond to treatment with meropenem.Similar to,drug-resistant plasmids in the bacterial structure ofcontribute to its virulence and resistance,but thehas the higher-risk antibiotic resistance-related genes sequences,thus giving it higher virulence and resistance[10,11].Recent clinical observations have shown that tigecycline and polymyxin display higher rates of treatment success in hypervirulentinfection than other antibacterial drugs such as carbapenem[12].Moreover,a combination of treatments is preferred to monotherapy in cases of severe infections[13,14].Unfortunately,treatments to targetinfection were not prescribed here because the patients’ illness rapidly progressed before genotypingresults were available.

As well illustrated by our case,subspecies can be rapidly fatal although their presence may often be overlooked due to the limitations of routine clinical examinations.This case should raise awareness among clinicians to considersubspecies infections,especially in cases of unexplained fever or other suspicious clinical presentations that may indicate this condition.Moreover,this case highlights the need to introduce genetic techniques into current clinical practices,especially for the early diagnosis of severe infections.

CONCLUSION

In summary,we have reported a patient dead with fatal infection caused by.This fatal infection was identified by PMseq-DNA Pro high throughput gene detection assay.This case calls attention tosubspecies infections and the need for early introduction of genetic technology in critically ill patients.

ACKNOWLEDGEMENTS

We thank Dr.Zuo MM for proofreading of the manuscript.

FOOTNOTES

Long DL and Wang YH completed the collection of clinical data;Wang JL,Mu SJ,Chen L,and Shi XQ contributed to the compilation of data and production of charts;Li JQ analyzed all data and wrote the manuscript.

47. Her innocence would be proved: The sister s innocence is accepted until the third event when coincidence is no longer considered. Three witnesses are often required to prove guilt. Return to place in story.

The patient reported a 5-year history of type 2 diabetes mellitus(T2DM)and 7 years of suffering gout but had no prior medical history related to the current symptoms.

We have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

In the 1980s, one young lady issued a public pronouncement dismissing（） all men under the height of 1.70 meters as handicapped . It was met with an avalanche1（） of responses from virtually all unmarried women in the nation.

All authors declare that they have no competing interests to disclose.

Written informed consent was obtained from the patient’s daughter for publication of this case report and any accompanying images.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: http://creativecommons.org/Licenses/by-nc/4.0/

China

Da-Li Long 0000-0002-4846-2939;Yu-Hui Wang 0000-0002-4990-1286;Jin-Long Wang 0000-0002-2801-9518;Si-Jie Mu 0000-0002-0613-7935;Li Chen 0000-0001-7157-7104;Xian-Qing Shi 0000-0003-2340-2945;Jian-Quan Li 0000-0003-2281-9773.

53. The wicked mother came to no good end: In The Seven Ravens, the wicked step-mother was taken before the judge, and put into a barrel filled with boiling oil and venomous snakes, and died an evil death. Return to place in story.

Yan JP

Wang TQ

One day Catherine was sitting in her own room when suddenly the door flew open, and in came a tall and beautiful woman holding in her hands a little wheel

Yan JP