Multisystem Involvement in a Patient with MDR Klebsiella Pyelonephritis and Sjogren’s Syndrome- A Complex Case Report

Abstract

A 53-year-old female with multiple comorbidities—Type 2 Diabetes Mellitus, Systemic Hypertension, Dyslipidemia, Coronary Artery Disease, Obstructive Airway Disease, and a suspected connective tissue disease—presented with acute systemic symptoms and was diagnosed with bilateral pyelonephritis due to MDR Klebsiella pneumoniae, alongside evidence of Sjögren’s syndrome and evolving interstitial lung disease (ILD). Clinical Presentation:The patient presented with fever, dyspnea, generalized weakness, and reduced urine output. She also reported dryness of mouth and eyes, consistent with Sjögren’s syndrome. Physical examination showed tachycardia, bilateral basal crepitations, pedal edema, and mild respiratory distress. Laboratory assessment revealed anemia (Hb 8.5–10.4 g/dL), elevated inflammatory markers (WBC 11,500/mm³, ESR 34 mm/hr, CRP 8.3 mg/L), prolonged PT (23.21 sec), and INR of 1.81 indicating anticoagulation effect. Autoimmune screening showed positive SSA/Ro, SSB/La, and Ro-52 antibodies, confirming Sjögren’s syndrome. Investigations:CT chest demonstrated diffuse mosaic attenuation, ground-glass opacities, tiny subpleural nodules, and bilateral mild pleural effusion, suggesting infective pathology with possible early ILD. Doppler studies of lower limbs revealed diffuse atherosclerotic changes with hemodynamic stenosis, but no DVT. Ultrasound abdomen confirmed bilateral mild pyelonephritis. Renal function remained stable. Management:The patient received broad-spectrum antibiotics, including Meropenem, Cefoperazone-Sulbactam, Doxycycline, and supportive agents. Pantoprazole, diuretics, BIPAP support, and nebulization (Duolin, Budecort/Budamate) were administered for respiratory improvement. Chronic cardiac medications—Aspirin, Clopidogrel, Atorvastatin, Amiodarone, Metoprolol—were continued. Autoimmune disease was managed with Wysolone, OXCQ, Gabapentin, and symptomatic therapy. Insulin (Huminsulin 50/50 and Ryzodeg) was initiated for glycemic control. Constipation and gastritis were managed with Looz and Ulgel. Conclusion:The patient showed gradual improvement in fever, respiratory symptoms, and inflammatory markers. Renal parameters stabilized, and oxygen requirement reduced with BIPAP support. Discharge medications included steroids, antihypertensives, ILD-related therapy, insulin, and supportive drugs. Early detection of Sjögren’s syndrome with associated ILD and timely antibiotic therapy for MDR infection were crucial for recovery. Close follow-up with rheumatology, pulmonology, and nephrology is essential to monitor disease progression and prevent complications.

Keywords

Introduction

Patient with multiple chronic illness often present with overlapping clinical features that complicates diagnosis and treatment. Elderly individuals are particularly vulnerable to severe infections due to altered immunity and existing systemic diseases. This case report presents a 63 yrs old female with known Type 2 diabetes mellitus, Systemic hypertension, dyslipedemia, and coronary artery disease., who was admitted with fever, cough, and breathlessness.

Further evaluation revealed bilateral pyelonephritis caused by multiple-resistant klebsiella pneumonia. The patient was also diagnosed with Sjogren’s syndrome and was under evaluation for connective tissue disease-associated interstitial lung disease. Laboratory investigation showed severe anemia, markedly raised inflammatory markers, and abnormalities in coagulation parameters. Radiological imaging demonstrated bilateral lung parenchymal involvement with gourd-glass opacities and pleural effusion, supporting an infectious and inflammatory process.

This case highlights the clinical challenges in managing drug-resistant infections  in patients with autoimmune disease and multiple metabolic comorbidities, and underscores the importance of early diagnosis, appropriate antimicrobial therapy and a multi-dispensary treatment approach.

CASE REPORT

A  53 –years female patient was admitted on general medicine department with multiple comorbidities – Type 2 Diabetes Mellitus, Systemic Hypertension, Dyslipidemia, Coronary Artery Disease, Obstructive Airway disease, and a suspected connective tissue diseases - presented with acute systemic symptoms and was diagnosed with bilateral pyelonephritis due to MDR Klebsiella  pneumonia, along side evidence of Sjogren’s syndrome and evolving Interstitial lung disease.

T.ASPIRIN [75mg]p/o-OD, T.CLOPILET [75mg]p/o OD, T.ATORVASTATIN [40mg]p/o HS, T.AMIODERONE [200mg]P/O TDS, T.ACITRON [4mg]P/O OD, T.METOPROLOL [25mg]P/O BD these are regular medicine taken by the patient. On examination , the patient is hemodynamically stable with a pulse rate of 70bpm and respiratory rate of 18/min; peripheral perfusion is warm, CNS examination shows GCSE4V5M6, respiratory system reveals clear chest with equal air entry bilaterally, and per abdomen is soft and non – tender.

Based on clinical findings , the patient was started on broad Spectrum intravenous antibiotics. Inj. CEFOPERAZONE SULBACTUM [1.5g] IV twice daily was initiated to cover suspected bacterial infection, along with T.DOXYCYCLIN [100mg] twice daily. Gastric protection was provided  with Inj. PANTOPRAZOLE [40mg] once daily. In view of cardiac rhythm abnormalities, Amiodarone was administrated as per standard protocol. Respiratory symptoms were manged with nebulization using DUOLIN and BUDECORT, along with oral bronchodilators and anti-histamines. Supportive treatment included antipyretics, cough syrups and intravenous fluids.

Over the course of hospitalization, the patient showed steady clinical improvement. Fever subsided, respiratory symptoms reduced , and vital parameters remained stable. Antibiotics and nebulization were gradually stepped down and the patient was discharged in stable condition with appropriate oral medication and follow up advice.

Investigations

CT Chest And Abdomen Screening:

Impression:  features are consistent with infective lung pathology on a background of suspected connective tissue disease–related lung involvement, associated with cardiac changes and bilateral renal infection. Clinical correlation and follow-up imaging are recommended.

Laboratory Investigations

Management

The patient requires multidisciplinary management addressing sepsis, cardiovascular disease, anemia, and uncontrolled diabetes. Continue targeted antibiotic therapy based on urine culture showing Klebsiella pneumoniae, with escalation or modification as per sensitivity and clinical response. Monitor inflammatory markers (CRP, WBC) regularly. Anemia (Hb 7–8 g/dL) should be managed with packed red cell transfusion as indicated, along with evaluation for chronic disease–related anemia and iron status. Maintain cardiac management with antiplatelets (aspirin, clopidogrel), statin, beta-blocker, and amiodarone, while closely monitoring INR due to Acitron  therapy and adjusting doses to prevent bleeding. Address heart failure risk given elevated BNP with fluid balance, diuretics if required, and daily weight monitoring. Tight glycemic control is essential using insulin, with frequent blood glucose monitoring. Supportive care includes oxygen if needed, DVT prophylaxis, electrolyte correction, nutritional support, and physiotherapy. Regular reassessment and coordinated care between medicine, cardiology, and infectious disease teams are advised.

Follow Up

Patient advised review in Pulmonology OPD with CBC, CRP, LFT and RFT reports. Medications and home BiPAP to be continued as advised. At discharge, the patient was stable with improvement in breathing and infection. Ongoing follow-up planned for diabetes control, cardiac status and overall recovery.

Clinical Implication

Patient advised review in Pulmonology OPD with CBC, CRP, LFT and RFT reports. Medications and home BiPAP to be continued as advised. At discharge, the patient was stable with improvement in breathing and infection. Ongoing follow-up planned for diabetes control, cardiac status and overall recovery.

CONCLUSION

The patient showed gradual improvement in fever, respiratory symptoms, and inflammatory markers. Renal parameters stabilized, and oxygen requirement reduced with BIPAP support. Discharge medications included steroids, antihypertensives, ILD-related therapy, insulin, and supportive drugs. Early detection of Sjögren’s syndrome with associated ILD and timely antibiotic therapy for MDR infection were crucial for recovery. Close follow-up with rheumatology, pulmonology, and nephrology is essential to monitor disease progression and prevent complications.

ACKNOWLEDGEMENT

I would like to express my sincere gratitude to Ezhuthachan College Of Pharmaceutical Sciences for providing the necessary academic support and facilities to complete the case report.

I am deeply  thankful to our respected teachers and clinical mentors for their valuable guidance,

Encouragement , continues support throughout the preparation of this manuscript. I also extend my sincere thanks to the Department of General Medicine and all healthcare professionals involved in the management of this case for their cooperation and clinical assistance.

I would like to acknowledge my co-authors for their contribution and teamwork in completing this work successfully. Finally, I express my heartfelt gratitude to my family and friends for their constant motivation and support.  

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