International Journal of Advances in Medicine

Shifa F et al. Int J Adv Med. 2025 Jul;12(4):459-461

http://www.ijmedicine.com

pISSN 2349-3925 | eISSN 2349-3933

Case Report

DOI: https://dx.doi.org/10.18203/2349-3933.ijam20251947

When the skin speaks: cutaneous vasculitis complicating a Klebsiella urinary tract infection

Fathima Shifa*, Apurva Rao K. S.

Department of Medicine, Yenepoya Medical College Hospital, Mangalore, Karnataka, India

Received: 03 May 2025

Accepted: 06 June 2025

*Correspondence:

Dr. Fathima Shifa,

E-mail: 1611shifa1981@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Cutaneous small-vessel vasculitis (CSVV) occurs due to leukocytoclastic vasculitis of dermal post-capillary venules. It can be triggered by infections, autoimmune conditions, or medications. Our case report highlights a rare association between CSVV and a urinary tract infection caused by Klebsiella pneumoniae in an immunocompetent individual. A 31-year-old female with no prior known comorbidities presented with painful, pruritic lesions over both lower limbs and right arm preceded by gastrointestinal symptoms. On examination, there were erythematous macules, crusted plaques and haemorrhagic vesicles noted. A skin biopsy confirmed CSVV. Autoimmune markers were negative, while complement C3 levels were reduced. Urine culture grew Klebsiella pneumoniae, suggesting a post-infectious etiology. The patient was treated with antibiotics and steroids resulting in marked clinical improvement. Infections are common triggers of CSVV, however Klebsiella pneumoniae is an uncommon cause, particularly in immunocompetent individuals. This case underlines the importance of considering uncommon etiologies in the differential diagnosis of CSVV and emphasizes that prompt identification and treatment of the underlying infection can lead to complete resolution. This case contributes to the limited literature on Klebsiella pneumoniae-associated CSVV in immunocompetent individuals and underscores the value of biopsy, infectious work-up, and early therapy in achieving good outcomes.

Keywords: Klebsiella pneumonia, Leukocytoclastic vasculitis, UTI, Immunocompetent

INTRODUCTION

Cutaneous small-vessel vasculitis (CSVV) is a skin-limited variant of systemic vasculitis caused by leukocytoclastic vasculitis of postcapillary venules.1,2 It can be idiopathic or secondary to infection, medication, connective tissue disease, or malignancy among other causes. The most common clinical presentation is of symmetrically distributed palpable purpura of the lower extremities.3

Histopathology is the gold standard for diagnosis with features appearing 24-48 hours after lesions emerge.4 Our case report presents an unusual case of a post infectious biopsy proven CSVV which responded well to steroids and antibiotics in an otherwise healthy female.

CASE REPORT

A 31-year-old female, with no prior known comorbidities, presented with a history of painful and itchy lesions on her bilateral lower limbs since 10 days. Similar lesions also appeared on her right upper limb. The lesions initially appeared as erythematous macules but soon progressed into vesicles and bullae, which eventually crusted over. She also reported fever and joint pain for the past two days prior to hospitalisation. A week prior to onset of her skin symptoms, the patient had experienced abdominal pain and vomiting, which had resolved after treatment. On general examination, both lower limbs were edematous with multiple crusted plaques on the dorsum of both lower limbs with some tender erythematous macules and a few hemorrhagic vesicles scattered across the area. The right arm also showed a few similar lesions. No lymphadenopathy was noted. Laboratory investigations revealed elevated inflammatory markers. Dermatology consultation was done and a skin biopsy was performed. The pathology report showed features consistent with CSVV. To rule out autoimmune causes, an ANA (antinuclear antibody) profile and anti-neutrophil cytoplasmic antibody (ANCA) was sent, which came back negative. Complement C3 was found to be low, while C4 levels were normal, suggesting a possible immune response. On further evaluation, she was also diagnosed with an underlying urinary tract infection, and her urine culture grew Klebsiella pneumoniae, a possible trigger for her immune response. A rheumatology consultation was sought, and a diagnosis of probable post-infectious vasculitis was made.

The patient was started on an appropriate course of antibiotics and systemic steroids were initiated to manage the vasculitis. Over the following days, the patient showed marked improvement in her general condition, and her skin lesions began to heal. She was discharged and is on regular follow up.

Figure 1: Extravasation of RBCs seen in leukocytoclastic vasculitis.
Figure 1: Extravasation of RBCs seen in leukocytoclastic vasculitis.
Figure 2: Skin lesions noted at the time of onset of symptoms.
Figure 2: Skin lesions noted at the time of onset of symptoms.
Figure 3: Erythematous maculopapular lesions over right upper limb.
Figure 3: Erythematous maculopapular lesions over right upper limb.
Figure 4: Healing skin lesions after initiation of treatment.
Figure 4: Healing skin lesions after initiation of treatment.

DISCUSSION

CSVV, is an immune complex-mediated inflammation of post-capillary venules in the dermis. Among the identified causes, infections are well known triggers. In a retrospective study by Sais et al it was found that infections were responsible for approximately 15-20% of vasculitis cases. They cause type III hypersensitivity reaction with immune complex deposition and complement activation finally leading to leukocytoclasia.5 Most common bacterial pathogens are gram positive cocci like Staphylococcus aureus and Streptococcus pyogenes but our patient was diagnosed with a urinary tract infection caused by Klebsiella pneumoniae, a pathogen not commonly associated with CSVV.6-8 Klebsiella pneumonia is a gram negative bacilli with virulence factors like lipopolysaccharide (LPS) which can serve as a antigenic stimuli for triggering immune responses.9 While Klebsiella pneumonia is a frequent cause of UTI and can lead to severe complications such as pyelonephritis and bacteraemia, its association with cutaneous vasculitis is rare and seen typically in the setting of underlying comorbidities like diabetes, chronic kidney disease or any immunocompromised state.10 In this case, the patient had no known comorbidities, making the occurrence of Klebsiella-associated CSVV particularly notable. Cutaneous symptoms in post-infectious vasculitis appear 7-14 days after the triggering event, aligning well with the onset in this case.11 In our case, the negative ANA and ANCA panels ruled out autoimmune vasculitis and supports the diagnosis of isolated post-infectious cutaneous vasculitis, a diagnosis of exclusion. Biopsy is crucial for confirming the diagnosis, showing characteristic findings of fibrinoid necrosis, neutrophilic infiltration, and extravasated red blood cells.12 The treatment primarily focuses on antibiotic therapy to address the underlying infection. In our patient's case, the Klebsiella pneumoniae infection was successfully treated with appropriate antibiotics, leading to a resolution of both the infection and the vasculitis. Systemic corticosteroids may be used in more severe cases to manage the inflammatory response and control the symptoms of vasculitis. The prognosis is generally favourable when the underlying infection is treated promptly, as seen in our case.13,14

CONCLUSION

The case illustrates that even localised uncomplicated infections caused by Klebsiella pneumoniae, can trigger vasculitis even in patients with no prior comorbidities or immune deficiencies. Early diagnosis with skin biopsy and treatment of the underlying infection is crucial for management.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

  1. 1. Micheletti RG. Cutaneous small vessel vasculitis: a practical guide to diagnosis and management. Am J Clin Dermatol. 2023;24(1):89-95.
  2. 2. Lotti T, Ghersetich I, Comacchi C, Jorizzo JL. Cutaneous small-vessel vasculitis. J Am Acad Dermatol. 1998;39(5 Pt 1):667-90.
  3. 3. Goeser MR, Laniosz V, Wetter DA. A practical approach to the diagnosis, evaluation, and management of cutaneous small-vessel vasculitis. Am J Clin Dermatol. 2014;15(4):299-306.
  4. 4. Alpsoy E. Cutaneous vasculitis: an algorithmic approach to diagnosis. Front Med (Lausanne). 2022;9:1012554.
  5. 5. Jennette JC, Falk RJ. Small-vessel vasculitis. N Engl J Med. 1997;337(21):1512-23.
  6. 6. Sunderkötter C, Bonsmann G, Sindrilaru A, Luger TA. Cutaneous signs in vasculitis and infections. Clin Dermatol. 2015;33(5):528-44.
  7. 7. Lum PN, Woo PC, Wong SS, Yuen KY. Leukocytoclastic vasculitis complicating Klebsiella pneumoniae bacteremia. Diagn Microbiol Infect Dis. 2000;37(4):275-7.
  8. 8. Abdelnabi M, Cavazos A, Mittal N, Singh R, Luu Q, Wright J. Leucocytoclastic vasculitis secondary to urinary tract infection caused by extended-spectrum β-lactamase producing Klebsiella pneumoniae. BMJ Case Rep. 2023;16:e255395.
  9. 9. Sunderkötter C, Zelger B. Clinical classification of vasculitis. J Dtsch Dermatol Ges. 2018;16(6):619-33.
  10. 10. Chien JY, Tsai HC, Lee SSJ. Clinical features and outcomes of Klebsiella pneumoniae infection in immunocompromised patients. J Microbiol Immunol Infect. 2011;44(6):354-60.
  11. 11. Baigrie D, Crane JS. Leukocytoclastic Vasculitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025.
  12. 12. Jennette JC, Falk RJ, Bacon PA, Basu N, Cid MC, Ferrario F, et al. 2012 revised International Chapel Hill Consensus Conference nomenclature of vasculitides. Arthritis Rheum. 2013;65(1):1-11.
  13. 13. González-Gay MA, García-Porrúa C, Pujol RM, López-Lazaro L. Infectious causes of leukocytoclastic vasculitis: a retrospective study. J Clin Rheumatol. 2005;11(3):121-6.
  14. 14. Gupta AK, Arora P, Dhir V, Sinha S, Handa S. Klebsiella pneumoniae-associated leukocytoclastic vasculitis. Indian J Dermatol Venereol Leprol. 2007;73(3):206-8.