Implantable cardioverter defibrillator endocarditis caused by Klebsiella pneumoniae complicated by liver abscess and septic pulmonary embolism

A 63-year old diabetic male patient carrying an implantable cardioverter defibrillator (ICD) was hospitalized with a 7- day history of fever, notwithstanding an antibiotic therapy. The white-blood cell count was 11,000/mm³, the platelet count was 135,000/mm³ and C-reactive protein (CRP) 13 mg/dL. Chest X-rays showed right infiltrates. Ceftriaxone was started. Defervescence was rapid, but CRP was still 12 mg/dL after 6 days. A trans-thoracic ecochacardiogram (TTE) incidentally showed a liver hypoechoic lesion. A computed tomography scan revealed bilateral cavitated lung nodules and a large liver abscess. Klebsiella pneumoniae was isolated in blood cultures and TTE showed ICD endocarditis and a patent foramen ovalis. Levofloxacin and imipenem/cilastatin were started. The liver abscess was drained. After 30 days, the ICD was removed and re-implanted. At discharge, blood tests were within the normal range and the patient was asymptomatic. Follow up showed improvement of lung and hepatic lesions. To our knowledge, this is the second reported case of K. pneumoniae infective endocarditis with multiple septic emboli. Endocarditis should be suspected in presence of fever after the device implantation, in particular if risk factors are present.