Male patient, 38 years old, Chilean nationality, living in Italy for approximately two years.
In May 2011, the patient presented with a picture of right hip pain. A magnetic resonance imaging study showed neoformation tissue in the right iliac region, with adjacent muscle tissue in isolation.
A biopsy of the lesion was reported as non-Hodgkin lymphoma, lymphoplasmacytic isotype.
Associated with this, acute renal failure with hypercalcemia and proteinuria, mainly Bence Jones type, and a monoclonal component type IgD-lambda, were observed.
In June 2011, the patient was admitted to the Hematology Unit of the Hospital de Lucca, Italy, where a chemotherapy regimen with bortezomib plus dexamethasone was initiated.
In July 2011, renal biopsy was performed due to deterioration of renal function, which showed tubulointerstitial nephropathy, beginning with renal replacement therapy in the same center.
In August 2011, the patient was reassessed, who presented an increase in the size of the lesion and was admitted to the Hematology unit of the University Hospital of Pisa.
A VDT-PACE (bortezomib, thalidomide, dexamethasone, cisplatin, doxorubicin, cyclophosphamide, and chemotherapy stopped) scheme was indicated.
Prior to this, the patient would have undergone a partial gastrectomy due to a perforated peptic ulcer.
It was then decided to continue with a CHOP scheme (metalamide, doxorubicin, vincristine, prednisone), the first cycle in the same center.
In successive evaluations during hospitalization, the control CT scan showed an echo-resistant compromise from the right iliac wing to the intestinal loops, and a rectal swab-screening showed the presence of multidrug-resistant Klebsiella pneumoniae.
Being at home in Italy, the patient presented several seizures that were attributed to metabolic disorders.
The presence of intracerebral lesions was ruled out.
He was referred to the Hospital de Versilia, Italy. He received a second and third cycle of chemotherapy with CHOP scheme, erythropoietin 22,20 derocytes and 19,01,2012, respectively, presenting secondary stimulated colonic aplasia.
He traveled from Italy to Chile and was directly admitted from the Santiago airport on February 28, 2012 to the Medicine Department of the San Borja Arriarán Clinical Hospital, to coordinate hemodialysis and evaluation by the hematologic team.
The first hemodialysis procedure was performed on 03/01.2012 presenting fever so hemocultives were obtained with differential time to rule out a bloodstream infection associated with central venous catheter, and urocultive.
On March 6, 2012, a strain of K. pneumoniae resistant to all ami-not described by our country was isolated from the uroculculum. The cephalopenic susceptibility quinolones, β -cell contact halos,
In addition to this, a non-responder gram-negative bacillus was isolated from two series of hemocultives of differential positivity time. The laboratory of asymptomatic microbiology of the Hospital Clínico bacteritrbacter University of Chile subsequently identified as an asymptomatic
On March 8, 2012, the Microbiology Laboratory and the Infection Control team obtained the epidemiological history of the patient's origin (hospital in Italy).
Faced with this antecedent, the possible presence of imported carbapenemase KPC was ruled out, indicating the microbiological study of KPC serving by rectal swab.
The urocultive was repeated, the first transmission was initiated and the first communication was made via email with the treating physician treating ESBL in order to consult if the multi-drug resistant KE pneumoniae was identified.
A new staging study with imaging revealed diffuse bone involvement and extensive lytic lesion of the right iliac with tumor of soft tissues.
From the hemato-oncological point of view, the patient would be a candidate for palliative treatment given the current stage of the underlying disease and its poor general conditions.
On March 11, Italy confirmed KPC history.
It was possible to identify again a K. pneumoniae resistant to all antimicrobials except colitis and arthritis patterns with urocultive and rectal swabs, which were studied with conventional biochemical battery for identification of species and anti-diffusion CLSI.
Molecular Department of Resistance to the Surveillance Protocol agreed by the Collaborative Group of Resistance of Chile (Non-published data Reunion-Curso de Resistencia Santa Cruz 2009), the strain was derived to the Microbi Laboratory.
On March 12th, in vitro susceptibility determination by MIC to K. pneumoniae strain and Hodge and boronic acid phenotypic tests6 were performed according to CLSI standards.
The positive result was obtained for both phenotypic tests, confirming the presence of bKPC (group KPC-2/ KPC-3; KPC-3; TEM and βCmp; AMIGema type A burn, carX-1).
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Finally, the Instituto de Salud Pública confirmed the finding of KPC (KPC-2/KPC-3) on March 13.
