Dear Editor,
Concerning the case recently published in this journal,1 we report the case of a patient with haemodialysis who experienced septic shock owing to endocarditis, caused by Klebsiella oxytoca and Staphylococcus aureus.
Klebsiella spp is an atypical agent of infective endocarditis, reaching < 1.2% in primary valves and 4.1% in prosthetic valves.2 The most frequent aetiological agent is K. pneumoniae, which has only been found in 4 published cases of infection caused by K. oxytoca.3
We report the case of a 58-year-old male patient with stage V chronic kidney disease owing to lupus nephritis treated with haemodialysis through a permanent right jugular catheter. His previous medical history showed chronic ischaemic heart disease, hypertension and receiving treatment of corticosteroids. Having no previous symptoms, he ran a temperature of > 39º C and felt a general discomfort. The examination revealed signs of hypotension, tachycardia, grade III/VI heart murmur (heard everywhere else in the body) and temperature. The blood test findings were as follows: leukocytes: 25,900 (N: 90%, L: 4%, M: 6%), Hb: 9mg/dl, anisopoikilocytosis with spherocytes and macrocytes, hypersegmented neutrophils, positive direct Coombs¿s test and normal liver and pancreatic profiles. The abdominal ultrasound and the thorax X-ray did not show any interesting pathological data. These, in addition to a negative urine culture, ruled out any sources of infection in those areas. S. aureus and K. oxytoca were isolated in the blood cultures of the catheter and the peripheral blood cells. This is why a transthoracic echocardiogram was carried out, leading to the discovery of a 2.5 x 1.5cm wart in the posterior medullary velum of the mitral valve and a smaller-sized one in the anterior medullary velum of the tricuspid valve. Following these findings, a treatment of vancomycin and gentamycin was administered according to an antibiogram, which later revealed a spleen embolism and a cardiogenic shock, resulting to the patient¿s death.
K. oxytoca represents 0.5-0.6% of all isolations in bacterias; more than a third of those are polymicrobial infections and between 37 and 52% are nosocomial. The majority are caused by the biliopancreatic or urinary pathology, and the various types of infective endocarditis are extremely rare, with a very high mortality rate (49%) despite receiving adequate antibiotic treatment.4,5
Given the immunosuppression of our patients following a substitute treatment, its associated comorbidity and the risk of contracting nosocomial infections, a quick detection of infective endocarditis is necessary since an early antibiotic treatment reduces the high risk of morbidity and mortality.
