Eur J Clin Microbiol Infect Dis (2012) 31:981–989

DOI 10.1007/s10096-011-1396-6

ARTICLE

Clinical and phenotypic differences between classic

and hypervirulent Klebsiella pneumonia: an emerging
and under-recognized pathogenic variant
D. K. Pomakova & C-B. Hsiao & J. M. Beanan &
R. Olson & U. MacDonald & Y. Keynan & T. A. Russo

Received: 6 May 2011 / Accepted: 18 August 2011 / Published online: 15 September 2011
# Springer-Verlag 2011

Abstract The purpose of this study was to increase is described. Comparative in vitro and in vivo virulence
awareness, gain insight into acquisition, and assess the studies on this isolate (hvKP1) and four randomly chosen
virulence of the hypervirulent (hypermucoviscous) clinical blood isolates of “classic” K. pneumonia strains (cKP1-4)
variant (hvKP) that is entrenched in the Pacific Rim but were performed. Cases of hvKP infection are occurring in
emerging in Western countries. A case of community- Western countries and are under-recognized. A hyper-
acquired liver abscess with metastatic spread to the spleen mucoviscous phenotype is a surrogate laboratory marker
for this variant. The propensity of hvKP strains for
metastatic spread in non-compromised hosts is both a
D. K. Pomakova : T. A. Russo
Veterans Administration Western New York Healthcare System,
defining and unusual trait. The mode of acquisition in the
Buffalo, NY, USA described case was unclear but potential means are
discussed. hvKP1 was more resistant to complement and
D. K. Pomakova : J. M. Beanan : R. Olson : U. MacDonald : neutrophil-mediated bactericidal activity and was more
T. A. Russo
Department of Medicine,
virulent in a rat subcutaneous abscess model than cKP1-4.
University at Buffalo-State University of New York, Recognition of the hypermucoviscous phenotype, defined
Buffalo, NY, USA by a positive “string-test”, will alert the microbiologist or
clinician that the infecting strain may be a hvKP, which is
C.-B. Hsiao
Erie County Medical Center,
hypervirulent compared to cKP. This will improve our
Erie, NY, USA understanding of the epidemiology and clinical spectrum of
infection, which may be more extensive than appreciated.
C.-B. Hsiao : T. A. Russo
Department of Microbiology and Immunology,
University at Buffalo-State University of New York,
Buffalo, NY, USA Introduction

J. M. Beanan : R. Olson : U. MacDonald : T. A. Russo K. pneumoniae is the most important Klebsiella species
The Witebsky Center for Microbial Pathogenesis,
from a medical standpoint, causing community-acquired,
University at Buffalo-State University of New York,
Buffalo, NY, USA long-term care, and nosocomial infections. Klebsiella
species are broadly prevalent in the environment and
Y. Keynan colonize mucosal surfaces of mammals. In healthy humans,
Department of Medical Microbiology, University of Manitoba,
K. pneumoniae colonization rates range from 5 to 35% in the
Winnipeg, Manitoba, Canada
colon and from 1 to 5% in the oropharynx; the skin is usually
T. A. Russo (*) colonized only transiently. Person-to-person spread is the
Department of Medicine, Division of Infectious Diseases, predominant mode of acquisition. Particularly in developed
University at Buffalo-State University of New York,
Western countries, most Klebsiella infections due to “classic”
3435 Main St., Biomedical Research Building (Room 141),
Buffalo, NY 14214, USA K. pneumoniae (cKP) now occur in hospitals and long-term
e-mail: trusso@acsu.buffalo.edu care facilities. The most common clinical syndromes due to
982 Eur J Clin Microbiol Infect Dis (2012) 31:981–989

cKP are pneumonia, urinary tract infection, abdominal strongly associated with strains that cause CA-PLA and
infection, intra-vascular device infection, surgical site infec- appears to be a surrogate marker. This phenotype has been
tion, soft tissue infection, and subsequent bacteremia. semi-quantitatively defined by a positive “string test”,
Historically, cKP caused a severe community-acquired which is the formation of a viscous string >5 mm in length
pneumonia, primarily in alcoholics. This syndrome is still when bacterial colonies on an agar plate are stretched by an
observed with some frequency in Africa and Asia, but has inoculation loop.
become increasingly uncommon in North America and The majority of cases of prototypical hvKP infection
Europe [1]. The acquisition of multi-drug resistance by cKP (e.g. CA-PLA) have been reported from the Pacific Rim
has been one of the critical features that have enabled it to be and as a result are less well recognized outside of that
a successful healthcare-associated pathogen. This has included region. In this report we will discuss a case of hvKP that
the acquisition of extended-spectrum β-lactamases and carba- was acquired in Buffalo, New York, related questions on
penemases, including the recently described New Delhi the mode of acquisition, and some laboratory-based caveats
metallo-β-lactamase (NDM-1) [2]. Multi-drug resistant on hvKP. Data is also presented, which compares the
(MDR)-cKP strains have been responsible for a number of relative virulence of hvKP to cKP isolates. An increased
nosocomial infection outbreaks in intensive care units and awareness of this emerging and highly virulent pathogen
neonatal nurseries. will enable a more comprehensive understanding of its
However, a new, hypervirulent clinical variant of evolving epidemiology and the spectrum of infections it
Klebsiella pneumoniae (hvKP) has emerged over the last causes.
decade. Initial reports were from the “Pacific Rim”, but
more recently hvKP is an emerging pathogen in the United
States, Canada, Europe, Israel, South Africa, Australia and Material and methods
elsewhere [3–7]. At first, infection due to hvKP was
clinically defined and distinguished from traditional infec- Strain description
tions due to cKP by: (1) presenting as community-acquired
liver abscess (CA-PLA), (2) affecting patients lacking a hvKP1 was isolated from the blood and liver abscess of a
history of hepatobiliary disease, and (3) a propensity for previously healthy 24-year-old male from Buffalo, New
causing metastatic spread to distant sites in 11–80% of York. cKP1-4 were randomly chosen blood isolates from
cases (e.g. lungs, pleura, prostate, bone, joints, kidneys, patients hospitalized at the Veterans Administration
spleen, muscle/fascia, soft-tissue, skin, eyes, and central Western New York Healthcare System. cKP1 has a mucoid,
nervous system [CNS]) [3, 5, 8–14]. hvKP infection but not a hypermucoviscous phenotype. All strains are
frequently occurs in diabetics and Asians, but hosts are grown in Luria-Bertani (LB) medium unless stated other-
often young and healthy and infections are described in wise and were maintained at −80°C in 50% (LB) broth and
all ethic groups. hvKP is associated with a significant 50% glycerol. The detection of rmpA in hvKP1 was PCR-
mortality rate, ranging from 3–32% [1, 11, 12, 14–16]. based (forward, 5'-ACTGGGCTACCTCTGCTTCA-3',
Further, survivors with metastatic spread often suffer reverse, 5'-CTTGCATGAGCCATCTTTCA-3'). hvKP1
catastrophic morbidity such as loss of vision and neuro- was serotypes using anti-K1-6 antisera (Klebsiella antisera
logic sequelae [11, 12]. From a clinical perspective, hvKP “Seiken” set,, Denka Seiken, Tokyo, Japan).
possesses novel features for an enteric gram-negative
bacillus (GNB). Invasive infection (e.g. liver abscess) is In vitro growth in LB medium
an unusual occurrence for a healthy individual. Further,
although metastatic spread is common for certain gram- Growth in LB medium was performed as described with
positive pathogens such as Staphylococcus aureus and aliquots removed for bacterial enumeration at 0, 3, 6 and 24
Streptoccocci, it is uncommon for most extraintestinal hours [17].
pathogenic GNB (e.g. extraintestinal pathogenic Escher-
ichia coli, Proteus, and cKP). Serum bactericidal assay
Infections due to hvKP are distinguished from those due
to cKP primarily on clinical grounds with CA-PLA being Complement-mediated bactericidal assays were performed
the defining syndrome. However, the lack of an unequiv- as described except that aliquots were removed for bacterial
ocal genotypic/phenotypic marker(s) for hvKP has preclud- enumeration at 0, 3, 6 and 24 hours [17, 18].
ed a comprehensive understanding of the prevalence and
spectrum of disease caused by these strains. Although a Neutrophil survival assays
100% sensitive and specific marker for hvKP strains is
presently lacking, a hypermucoviscous phenotype has been These assays are performed as described [19].
Eur J Clin Microbiol Infect Dis (2012) 31:981–989 983

Rat subcutaneous abscess model 103–104°F persisted, his abdominal pain evolved to
primarily involve his right upper quadrant, and he returned
The rat subcutaneous abscess model was approved by the to hospital and was admitted. Past medical history was only
University at Buffalo and Veterans Administration Institu- significant for asthma for which he intermittently used a
tional Animal Care Committees. Dalhoff originally steroid inhaler. There was no recent travel or exposure to
described this model, which was modified by our group [18, pets, other animals or sick contacts. He had lived in New
20–22]. In brief, a space is created by subcutaneous injection York City with his parents since he came to the USA and
of 30 ml of air into the back of anesthetized Long-Evans rats moved to Buffalo, NY to study at the nursing school
(200–225 grams), which is injected with 1 ml of 1% croton several months prior to admission. His last visit to Asia was
oil in a filter-sterilized vegetable oil vehicle. This space to Vietnam 3 years earlier. He denies smoking, intravenous
matures into an encapsulated, fluid-filled (8–12 ml) drug use, or alcohol intake. He did not recall any skin
“abscess” over 6–8 days. PMNs will migrate into the abscess breaks or skin infections prior to becoming ill. He ate at a
in response to appropriate chemotactic signals. The abscess’ Sushi Bar 3 weeks prior. He is sexually active with his
subcutaneous location enables multiple injections and sam- girlfriend who visited China 2 years earlier. There were no
plings to be performed over time. On day 8, a given Klebsiella other sexual contacts with individuals who had visited
strain being assessed was injected into the abscess of an Pacific Rim countries. Interestingly, 3 months ago he was
anesthetized animal, resulting in estimated starting abscess visited by friends who had visited North Korea and by
concentration of 4–6×104 cfu/ml. Within one minute after the friends from Japan; however they did not bring any food
bacteria were injected into the abscess 0.5 ml of abscess fluid with them to Buffalo. On physical exam he was in acute
was removed to measure the actual starting bacterial titer. distress, diaphoretic, and had dry mucosa and skin. A
Fluid aliquots (0.5 ml) were subsequently obtained from temperature of 104.6°F, a pulse of 130/minute, and a blood
anesthetized animals 3, 6, 24, and 48 hours after the initial pressure 90/54 mmHg was recorded. He was lethargic but
bacterial challenge and bacterial titers were enumerated. able to follow commands. Abdominal exam revealed
hyperactive bowel sounds and diffuse abdominal pain with
Statistical analyses right upper quadrant tenderness, but no peritoneal signs.
The admission white blood cell count was 14,500/mm
Data are presented as mean±SEM. P values of 0.05/n [3] (68% polymorphonuclear, 25% bands, 2% metamyelo-
(n=the number of comparisons) are considered statistically cytes, 5% lymphocytes), hemoglobin 15.5 gm/dl, and
significant based on the Bonferroni correction for multiple platelets 69,000/mm [3]. The sodium was 132 mEq/L,
comparisons, and P values >0.05/n but <0.05 are considered chloride 93 mEq/L, blood urea nitrogen 26 mg/dl, creati-
as representing a trend. To normalize in vitro and in vivo data nine 1.9 mg/dl, glucose 161 mg/dl, AST 242 U/L, ALT 372
log10 transformed values were utilized, the area under each U/L, ALP 76 U/L, and amylase and lipase were within the
curve was calculated, and these areas compared using two- normal range. A CT scan of abdomen demonstrated a large,
tailed unpaired t tests (Prism 4 for MacIntosh, GraphPad heterogeneous, multi-septated, hypodense irregularly mar-
Software, Inc.). ginated lesion involving the posterior segment of the right
hepatic lobe that was consistent with an abscess (Fig. 1). A

Results

A case of hvKP was acquired in Buffalo, New York,

presenting as community-acquired pyogenic liver abscess
(CA-PLA)

A 24-year-old Vietnamese male, who immigrated to the

USA at age 10, presented with 4 days of nausea, vomiting,
and fever. A temperature of 104.6°F was recorded at home
and was associated with rigors, chills, generalized weakness
and muscle aches. He also developed diarrhea with three to
four loose bowel movements per day associated with
diffuse abdominal pain and cramps. No blood in the stools
Fig. 1 hvKP1 is a model pathogen for studying hvKP. An image from
was noted. Two days prior to admission the patient an abdominal CT scan from a previously healthy 24-year-old
presented to the emergency room but he was discharged Vietnamese male. His primary liver abscess (red arrow) with probable
with a diagnosis of viral enteritis. High-grade fevers of metastatic spread to the spleen (black arrow) is shown
984 Eur J Clin Microbiol Infect Dis (2012) 31:981–989

splenic lesion was also noted, which presumably repre- made on this isolate during the performance of additional
sented metastatic spread (Fig. 1). Empirical piperacillin / phenotypic studies. Pellet formation was quite poor after
tazobactam and metronidazole was initiated along with centrifugation.
rehydration, which resulted in improvement of his blood
pressure and renal function. A gram-negative bacillus grew hvKP1 is more virulent when compared with four “classical”
from the admission blood cultures in less than 24 hours. K. pneumoniae strains
Subsequently, stool cultures did not disclose bacterial
enteric pathogens, including E. coli 0157, Yersinia, Plesio- The clinical behavior of hvKP1, namely, causing a
monas, and Clostridium difficile. Stool evaluation for ova serious life-threatening infection in a young, healthy
and parasites was unrevealing and serologies for hepatitis ambulatory host and reports on these variants from the
B, C, and human immunodeficiency viruses were negative. Pacific Rim are consistent with the hypothesis that these
Initially, computerized tomography guided drainage of the strains are more virulent than “classical” K. pneumoniae
abscess was performed by the placement of a pigtail isolates. Therefore, a series of studies was performed to
catheter in the abscess cavity. However, drainage was test this hypothesis.
incomplete despite the removal of 120 ml of reddish-tan,
non foul-smelling fluid. Subsequently, open surgical drain- The growth of hvKP1 and cKP1-4 is similar in the laboratory
age was performed and the patient eventually recovered medium LB broth
after a prolonged antimicrobial course.
As a first step, the growth of hvKP1 and four randomly
Microbiologic studies of the hvKP1 isolate chosen blood isolates of classic K. pneumoniae strains
(cKP1-4) was assessed in LB medium. The growth of
Klebisella pneumoniae was isolated from both blood these strains was similar in this rich laboratory medium
cultures and liver abscess fluid and was named (Fig. 3).
hypervirulent K. pneumoniae 1 (hvKP1). Both isolates
demonstrated the same antimcrobial susceptibility pat- hvKP1 is more virulent than cKP1-4 in the rat subcutaneous
tern, being only resistant to ampicillin. However, the abscess model
colonies were extremely mucoviscous compared to the
other Klebsiella strains isolated in the laboratory. This The growth and/or survival of hvKP1 and cKP1-4 were
prompted the performance of a “string-test”, which was assessed in the rat abscess model [18, 22]. The growth and/
positive, thereby establishing a hypermucoviscous phe- or survival of hvKP1 was significantly greater than all four
notype (Fig. 2). It can be inferred from these data that cKP blood isolates assessed (Fig. 4). The initial growth
with hvKP1 the hypermucoviscous phenotype does not
decrease antimicrobial susceptibility. The isolate was
shown to possess a K2 capsular serotype and the presence
of the rmpA gene, a gene responsible for the hyper-
mucoviscous phenotype [23] was established by PCR-
mediated amplification. An important observation was

Fig. 2 hvKP1 possesses the hypermucoviscous phenotype. This Fig. 3 The growth of hvKP1 and cKP1-4 are similar in laboratory
phenotype has been semi-quantitatively defined by a positive “string medium. hvKP1 and cKP1-4 were grown in the rich laboratory
test”, which is the formation of a viscous string >5 mm in length when medium Luria-Bertani broth. Growth was measured by optical density
bacterial colonies on an agar plate are stretched by an inoculation loop at Å600
Eur J Clin Microbiol Infect Dis (2012) 31:981–989 985

Fig. 4 There is a significant increase in the growth/survival of the Fig. 5 There is a significant increase in the growth/survival of the
hypermucoviscous strain hvKP1 in the rat abscess model, compared to hypermucoviscous strain hvKP1 in vitro in 90% human serum,
the “classical” strains cKP1-4. Growth/survial of K. pneumoniae compared to the “classical” strains cKP1-4. Growth/survial of K.
strains hvKP1, cKP1, cKP2, cKP3, and cKP4 in the rat abscess model. pneumoniae strains hvKP1, cKP1, cKP2, cKP3, and cKP4 in vitro in
All strains are blood isolates. Data are mean±SEM for n=4. To 90% human serum. All strains are blood isolates. Data are mean±
normalize data, log10 transformed values were utilized, the area under SEM for n=3. To normalize data, log10 transformed values were
each curve was calculated and compared using two-tailed unpaired t utilized, the area under each curve was calculated and compared using
tests (Prism 4 for MacIntosh, GraphPad Software Inc.). * hvKP1 two-tailed unpaired t tests. * hvKP1 compared to: cKP1, cKP2, cKP 4,
compared to: cKP1, P<0.0001; cKP2, P=0.002; cKP2, P=0.001; P<0.0001; cKP3, P=0.0007
cKP4, P=0.003

hvKP1 is resistant to neutrophil-mediated bactericidal

observed for hvKP1 over the first 6 hours was very activity in vitro
unusual. Nearly all of the wild-type, virulent, blood
isolates previously tested at this starting inoculum in As a next step we assessed the ability of hvKP1 to resist
this model (e.g. E. coli, A. baumannii, S. aureus) have killing by human neutrophils, another critical component of
an initial decrease in titer over this time frame [18, 22]. the innate immune system, compared to cKP1-4. Survival
This suggests that hvKP1 has a unique, above-average of strains was measured at 60 minutes in the presence and
ability to grow and/or survive in vivo. Although the absence of human neutrophils as described [24]. The wild-
difference in growth and/or survival of hvKP1 compared type extraintestinal pathogenic E. coli strain CP9 was used
to cKP2-4 was not as great at 48 hours, the highly as a positive control. Since we did not possess any strain
significant differences observed over the first 6–24 hours specific Klebsiella antisera, we utilized 1% human serum, a
are critical since the initial interaction of pathogen with concentration determined in a pilot experiment not to
host defenses may dictate whether infection will be possess complement mediated bactericidal activity to
established or if the offending pathogen will be cleared. cKP1-4. hvKP1 was resistant to neutrophil-mediated
We hypothesize that this is one of the critical traits hvKP bactericidal activity. In contrast, cKP2-4 were significantly
strains possess, which in turn contributes to their novel killed (Fig. 6). Interestingly, cKP1, which possesses a
clinical phenotype. mucoid (but not a hypermucoviscous) phenotype, was also
resistant to neutrophil-mediated bactericidal activity. How-
hvKP1 is more resistant to 90% human serum in vitro ever, in contrast to hvKP1, cKP1 is killed by 90% human
than cKP1-4 serum in vitro and is killed in vivo (Figs. 4 and 5). These
data support the concept that resistance to neutrophil-
The innate response is instrumental in determining whether mediated bactericidal activity in vivo is a second mecha-
extracellular bacterial pathogens such as Klebsiella are nism responsible for the increased growth/survival of
successfully cleared or establish an infection. The comple- hvKP1 in vivo. These data also suggest that ability to resist
ment system is a critical component of the host’s innate both complement and neutrophil-mediated bactericidal
immune system. Therefore we tested whether hvKP1 was activity is critical for hvKP1’s virulence phenotype.
more resistant to the complement-mediated bactericidal
activity than cKP1-4 by assessing their growth and/or
survival in 90% human serum. The growth/survival of Discussion
hvKP1 was significantly greater than cKP1-4 (Fig. 5).
These data support the concept that resistance to This report describes the first reported case, to our
complement-mediated bactericidal activity in vivo is one knowledge, of CA-PLA due to a hypervirulent variant of
mechanism responsible for the increased growth/survival of K. pneumoniae in the Eastern half of the United States.
hvKP1 in vivo. Although such cases have been extensively described in the
986 Eur J Clin Microbiol Infect Dis (2012) 31:981–989

to developing infection, the subject in this case was visited

by friends who had travelled from North Korea and Japan
and they did not bring any food with them. Although there
was no molecular epidemiologic data to support that hvKP1
was transported by one of these individuals and subse-
quently transmitted to the case patient, it is speculative but
biologically plausible possibility since many cases have
been described in the Pacific Rim and none in the eastern
United States. Klebsiella is a common colonizer of the
gastro-intestinal tract and person-to-person spread is well
documented. Two logical routes of entry exist for hvKP,
both unproven. The first is via occult breaks in the skin,
which commonly occurs with S. aureus. The second is
invasion through the intestinal tract, which is seen with S.
typhi. This possibility is supported by a recent study that
Fig. 6 The growth/survival of the hypermucoviscous strain hvKP1 is identified a variety of factors in a hvKP strain that enabled
significantly increased in vitro after exposure to human neutrophils intestinal colonization and/or invasion from the intestinal
compared to the “classical” strains cKP2-4. Neutrophil-mediated tract to extraintestinal sites [26]. It is interesting in this case
bactericidal activity against the E. coli strain CP9 (w.t.)(positive
control) and the K. pneumoniae strains hvKP1 and cKP1-4. CP9 was that the patient initially experienced gastrointestinal symp-
opsonized with 1:100 dilution of rabbit polyclonal anti-CP9 antiserum toms. Taken together, although local acquisition cannot be
and the K. pneumoniae strains were opsonized with 1% human serum. excluded, the most logical sequence of events appear to be
Approximately 1 x 105 cfu of each bacterial strain were added to wells that hvKP1 was transported from the Pacific Rim by the
that did or did not contain 5 x 105 purified human neutrophils (PMN).
Bacterial titers were determined at 60 minutes and bactericidal activity case patient’s friends, person-to-person transference
was calculated as the difference between bacterial titers (mean±SEM occurred resulting in colonization of the patient, and
of the log titer, n=3 for each strain) in the presence and absence of subsequent endogenous infection occurred though the
neutrophils. *Comparison of cfu for a given strain with or without gastrointestinal tract or via an occult break in the skin.
neutrophils at 60 minutes: P=0.0014; 0.0012; 0.0086; 0.003 for CP9,
cKP2, cKP3, cKP4, respectively (two-tailed unpaired t tests) Although no human cases of laboratory acquired-infection
have been reported as one might expect with an intestinal
route of entry, it would seem prudent that hvKP strains
Pacific Rim and have been reported from Europe, Africa, should be handled with caution in the laboratory until more
Australia, and North America, the general awareness of this data are available. Likewise, although there were no
emerging pathogen is not optimal. This case is illustrative secondary cases in Buffalo, appropriate hospital infection
of several cardinal features. First, this highly virulent control measures should be considered, given the virulence
pathogen has the ability to cause severe invasive disease of the organism. Lastly, it is reasonable to consider travel to
in ambulatory healthy hosts, such as described here. the Pacific Rim or exposure to people from that area as a
Secondly, metastatic spread is unusual in a non- risk factor for infection due to hvKP since acquisition leading
immunocompromised host for most extraintestinal patho- to colonization and subsequent infection from international
genic GNB such as Klebsiella, E. coli and Proteus. In this travel has been documented for MDR-Enterobaceriaceae,
case there was likely spread to the spleen. Klebsiella is an including Klebsiella [27, 28]. Appropriately-designed molec-
unusual cause of splenic abscess. However, in a recent ular epidemiologic studies that address the acquisition and/or
series from Korea, K. pneumonia was the second most mode of transmission of hvKP strains would be important.
common pathogen responsible for splenic abscess [25]. The A few laboratory caveats are worthy of discussion.
presence or absence of a hypermucoviscous phenotype was Recognition by the clinical microbiologist of the hyper-
not reported in these studies, but it is tempting to speculate mucoviscous phenotype will alert or assist the clinician in
that hvKP were the responsible pathogens. Lastly, since the recognizing that the infecting strain may be a hvKP.
majority of cases have been described in individuals of Improved laboratory identification may also improve our
Asian extraction it has been questioned whether this ethic understanding of the epidemiology and clinical spectrum of
background heightens the risk of infection. Although infection. If a hypermucoviscous phenotype is a valid
infection has also been described in non-Asians it is surrogate marker, the spectrum and number of infections
interesting that this case involved an individual of Vietnamese due to hvKP is more extensive than appreciated. A variety
extraction. of community-acquired primary extrahepatic infections
One of the most interesting clinical aspects of this case including renal, deep neck, and parotid gland abscesses,
was insights on the mode of acquisition. Three months prior mycotic aneurysm, osteomyelitis, subdural empyema,
Eur J Clin Microbiol Infect Dis (2012) 31:981–989 987

pulmonary empyema, and septic arthritis without concom- resistance, which interestingly possessed a mucoid, but
itant hepatic abscess have been described [16, 29]. In a non-hypermucoviscous phenotype. We were unable to
series of 200 cases of community-acquired KP bacteremia identify any other data comparing neutrophil-mediated
from China, 42% (83/200) possessed a hypermucoviscous bactericidal activity between hvKP and cKP strains.
phenotype. Of these 83 cases, 23% were primary bacter- Clearly the phenotype of hvKP has evolved, however the
emias, 21% were primary pneumonias, 11% were UTIs, 2% basis for this change is poorly understood. The majority,
were spontaneous bacterial peritonitis, and 37% were the but not all of the strains that cause CA-PLA, possess the
pathognomic CA-PLA±metastatic spread to the CNS, eye, gene that confers this phenotype, rmpA [35–38]. The
or pleural space [30]. The 14-day mortality in these 83 biochemical nature of the hypermucoviscous phenotype is
patients was 27%. A number of adult cases of primary unclear but appears to be distinct from the constitutive
community-acquired meningitis due to K. pneumonia have capsular serotype (e.g. K1, K2) and the surface polysac-
been reported from Taiwan, with mortality rates ranging charide colanic acid [23]. In some strains, rmpA is present
from 30–83% and survivors suffering significant neurologic on a large virulence plasmid and may be a surrogate marker
sequelae [15, 31–33]. Like the splenic abscess case series for other virulence factor [23, 39]. The capsule, especially
described above [25], the presence or absence of a hyper- serotypes K1 and K2, has long been known to be an
mucoviscous phenotype was not reported in these studies, important virulence factor in cKP [40–44]. Because the
but since KP is an exceedingly rare cause of primary majority of hvKP strains that caused CA-PLA were either a
meningitis in adults, it seems likely that hvKP were the K1 or K2 serotype, these capsular serotypes were initially
responsible pathogens. believed to be the critical virulence factor in this infectious
Other features of note are that pellet formation was quite syndrome [11, 36]. However, 23–33% of strains that cause
poor after centrifugation. Although it was not experimen- CA-PLA are non-K1/K2 isolates [36, 37, 45]. Further, since
tally established to be due to hypermucoviscous phenotype, the K1 and K2 serotypes were also present in non-CA-PLA
there was normal pelleting of the classical Klebsiella clonal groups that were significantly less virulent in a
strains. This may have important implications when trying mouse model, the authors concluded that the pathogenic
to concentrate the organism in certain body fluids such as potential of CA-PLA isolates resides with their genomic
pleural fluid, ascites, or cerebral spinal fluid. cKP1 appears background, not the capsular serotype [35]. The presence of
mucoid, but was “string test” negative. Therefore a mucoid a hypermucoviscous phenotype and selected capsular
colonial appearance does not equate to a hypermucoviscous serotypes (primarily serotypes K1 or K2), were initially
phenotype. A modified “string test” has also been proposed proposed to be defining characteristics of hvKP [3, 11, 36].
in which the string formation was >10 mm [30]. Although However, recent genomic characterizations established that
this seems reasonable, it is unclear whether this definition the genomic background, rather than the hypermucoviscous
will maintain sensitivity and increase specificity. phenotype or capsular serotype, defines hvKP pathogenicity
Data presented in this report lend further support that [35, 46, 47]. These data do not discount the potential
hvKP strains are more virulent than classical strains. importance of these traits in virulence but emphasize that
Although this would appear to be intuitive, limited data other virulence factors contribute to this novel phenotype.
exists. Most studies have compared differences in virulence
between different hvKP isolates. hvKP1 was more virulent Acknowledgements We thank the Clinical Microbiology laborato-
ries at Erie County Medical Center and the Veterans Administration
in a rat subcutaneous abscess model than cKP1-4. Meta-
Western New York Healthcare System for their sage advice and
static spread does not occur in the rat subcutaneous model. support. This work was supported in part by the National Institutes of
However, this model, which has not been used previously Health grant 1RZ1 AI 088318-01 AI (TAR) and by a Merit Review
to study hvKP, should prove useful for studying virulence grant from the Department of Veterans Affairs (TAR).
factors important for growth and survival within the
abscess, host-pathogen interactions, and treatment modali-
ties. Further, this model is efficient since multiple sampling References
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