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Abnormal morphological appearance of Klebsiella pneumoniae in blood culture: A microscopic observation

A 59‐year‐old female came to the medicine outpatient department with complaints of right flank pain, intermittent fever associated with chills and rigor, bilateral pedal edema without any urinary complains, decreased appetite and episodes of vomiting after intake of food since 5 days. On general examination, icterus was present, and the vitals were stable. On systemic examination, there were no significant findings. A provisional diagnosis of acute febrile illness was made, and the patient was admitted to medicine ward, and cefixime (200 mg BD) was started. She was afebrile during admission; hence, blood was not sent for culture and sensitivity. Her other laboratory results were as follows: total leukocyte count (17,000/cmm), neutrophils (88%), total bilirubin (4.7 mg/dL), direct bilirubin (1.18 mg/dL), indirect bilirubin (3.52 mg/dL), serum glutamic pyruvic transaminase (26 U/L), serum glutamic‐oxaloacetic transaminase (31 U/L), alkaline phosphatase (120 U/L), total protein (6.66 g/dL), albumin (3.40 g/dL), globulin (3.26 g/dL), and serum creatinine (1.67 mg/dL). She was not having HIV, Hepatitis B virus, or Hepatitis C virus infection. Urine culture showed insignificant growth. Ultrasonography of abdomen revealed cholelithiasis along with right‐sided mild hydroureteronephrosis (HUN) and pyelonephritis. Further, contrast‐enhanced computed tomography ‐ kidney, ureter, and bladder also revealed an approximately 9 mm × 7 mm calculus in the right lower ureter with moderate HUN. After about 2 days of admission, the patient developed fever, which was continuous in nature along with further increase in total leukocyte count (22,700/cmm) and neutrophil count (92.4%). A set of blood sample was sent for culture and sensitivity. One of the cultures (a) was positive at 2 days 19 h and another one (b) was positive at 3 days 5 h by automated culture system. Direct Gram stain from one of the culture bottles (a) showed plenty of Gram‐negative bacilli with a central bulge while Gram stain from other bottle (b) showed multiple long filamentous Gram‐negative bacilli with large central bulge, few even resembling fungal hyphae [Figure 1]. Identification and sensitivity of the isolate were performed both by conventional laboratory methods (biochemical reactions and Kirby‐Bauer method) and by automated Microscan walkaway‐96 plus system (minimum inhibitory concentration values are taken into account). Isolate from both the bottles was identified as Klebsiella pneumoniae, which was sensitive to antibiotics such as cefepime, ceftriaxone, ceftazidime, piperacillin‐tazobactam, ciprofloxacin, meropenem, imipenem, ertapenem, amoxiclav, gentamicin, tobramycin, aztreonam, amikacin, tigecycline, polymyxin‐B, and cotrimoxazole. Meanwhile, right‐sided Double J‐stenting was done, and the patient was prescribed meropenem, 1 g i. v QID and levofloxacin. She gradually became afebrile and improved clinically. Repeat blood culture sent after 5 days of antibiotic treatment, turned out to be negative. She was discharged with advice to follow‐up for removal of DJ stent and furthermore for review of ureteric stone and cholelithiasis in the concerned departments.