a 49 year - old afro - caribbean man from the island of saint kitts presented to a saint kitts hospital with a two - day history of fever , left shoulder pain , mild headache , vomiting and watery diarrhea . the patient had no significant medical history including no diagnosis of diabetes mellitus , no recent travel history , and denied alcohol , tobacco , or drug use . there had been a recent outbreak of dengue fever in saint kitts . on admission , the physical examination revealed dehydration and mild right basilar rales by pulmonary auscultation . laboratory studies showed a normal white blood cell count , hemoglobin , platelets , ( 5,900/mm , 13.1 g / dl , and 146,000/mm , respectively ) , but elevated serum glutamic oxaloacetic transaminase ( sgot ) 88 u / l ( normal levels : 15 - 37 u / l ) , and serum glutamic pyruvic transaminase ( sgpt ) 79 u / l ( normal levels : 30 - 65 follow - up laboratory studies demonstrated a rising white blood cell count of 13,200/mm with an increase in immature neutrophils ( a left shift ) suggesting acute inflammation . he developed thrombocytopenia with a platelet count of 36,000/mm ( normal levels : 150,000 to 400,000/mm ) and prolonged coagulation studies with a prothrombin time ( pt ) and partial thromboplastin time ( ptt ) of 34 ( normal : 11 - 13.5 ) and 47 ( normal : 25 - 35 ) seconds , respectively . he was transfused multiple units of fresh frozen plasma and platelets to maintain hemodynamic stability . on day eight , he was airlifted to mount sinai medical center , a tertiary care facility in miami beach , florida , for further management . upon arrival , he was afebrile ( t 98.0f ) , bradycardic ( 38 beats per minute ) , intubated , and unresponsive . subsequently , a computed tomographic ( ct ) scan of the abdomen revealed multiple liver abscesses with possible necrosis with the largest measuring abscess ( figure 1a ) . it was sensitive to the cephalosporins ( cefazolin , cefotaxime , and cefepime ) , the fluoroquinolones ( ciprofloxacin , levofloxacin ) , the aminoglycosides ( amikacin , gentamicin , and tobramycin ) , meropenem , pipercillin / tazobactam and trimethoprim / sulfa . the initial ct scan of the brain done on arrival to mount sinai was negative . however , follow - up ct of the brain seven days later showed a 2.7 cm abscess located in the frontal lobe . two days later an additional lesion developed in the left parietal region ( figure 1c ) . the biopsy demonstrated abundant acute and chronic inflammation with surrounding necrosis consistent with a liver abscess . the gram stain of the material showed many neutrophils , but no organisms . on the third day of culture , there was growth of a mucoid gram - negative lactose - fermenting bacillus identified as klebsiella pneumoniae . this isolate , henceforth referred to as fiums1 , had a characteristic hyperviscous phenotype as demonstrated by the formation of elongated ( > 5 mm ) mucoviscous strings when a loop was passed through a colony . three weeks after admission , he became afebrile , was extubated , and the brain and liver lesions improved radiologically ( figure 1b and 1d ) . he returned to saint kitts where he remained clinically stable and completed six weeks of antibiotic treatment . klebsiella pneumoniae , a member of the enterobacteriaceae family , is a gram - negative enteric bacillus that forms large mucoid colonies . though rare , this organism has been associated with bacterial liver abscesses and metastatic infections with a predominance of cases in taiwan 2 . this syndrome has several distinguishing characteristics from traditional liver abscesses including its community - acquired origin , absence of underlying hepatobiliary diseases , and the presence of other invasive complications including endophthalmitis , suppurative meningitis , brain abscess , necrotizing fasciitis , and osteomyelitis 4 . fang et al . reported that the invasive k. pneumoniae strains associated with this syndrome more often exhibited a hypermucoviscosity phenotype as demonstrated by extreme stickiness of these colonies on agar plate  producing a positive string test 9 . the hypermucoviscosity phenotype is highly associated with community - acquired k. pneumoniae bacteraemia that leads to distinctive invasive syndromes such as liver abscess , meningitis , pleural empyema or endophthalmitis 5 . recently , a number of genes have been identified as potential markers of virulence , including maga , which has a high association with the k1 serotype and is more prevalent in strains isolated from human liver abscesses 7 . the presence of maga from the k. pneumonia fiums1 ( 16s rrna sequence deposited as genbank accession number fj436718 ) was determined using pcr . the 1,282 bp gene was amplified using the maga forward primer ( 5'-ggt gct ctt tac atc att gc-3 ' ) and maga reverse primer ( 5'-gca atg gcc att tgc gtt ag-3 ' ) 7 . a maga product was not detected in the strain . to test for the k2 serotype , k2a ( 523 bp ) was amplified using the forward primer ( 5'-caa cca tgg tgg tcg att ag-3 ' ) and the reverse primer ( 5'-tgg tag cca tat ccc ttt gg-3 ' ) 8 . though maga has been implicated in the hypermucoviscosity phenotype , the maga gene has only been identified in 24% of clinical isolates 5 . thus , it is not surprising to find the k. pneumoniae fiums1 is maga - negative . in addition , the k2 serotype of k. pneumoniae is the second most common type of strain isolated from liver abscesses 8 . in conclusion , through culture methods and 16s rrna sequencing , the strain isolated from the liver abscess was verified as k. pneumoniae . the absence of maga gene and the presence of k2a in this isolate indicate that the hypervirulence of the strain is due to the k2 capsule . this form of k. pneumoniae has not been previously noted on the island of st . earlier identification of an infection caused by this hypervirulent serotype should result better patient prognosis .
klebsiella pneumoniae isolated in community - acquired pneumonia is increasingly found in primary pyogenic liver abscesses . 
 the presence of maga in k. pneumoniae has been implicated in hypermucoviscosity and virulence of liver abscess isolates . 
 the k2 serotype has also been strongly associated with hypervirulence . 
 we report the isolation of non - maga , k2 k. pneumoniae strain from a liver abscess of a saint kitt 's man who survived the invasive syndrome .