A Rare Presentation of Raoultella planticola-Associated Cholangitis in an Immunocompetent Patient

Introduction: Bacterial cholangitis occurs when there is regurgitation of infected bile into the circulation from increased biliary pressure secondary to biliary obstruction. Common bacterial causes include Escherichia coli, Klebsiella, Enterococcus, Enterobacter, Pseudomonas, and anaerobes. We present a rare case of Raoultella planticola associated Cholangitis in an immunocompetent patient. Case Description/Methods: A 101 year old female with history of hypertension, and no prior surgical history presented with right upper quadrant abdominal pain and subjective fevers for 2 days. She denies vomiting, diarrhea, or exposure to sick contacts. She was hypotensive but afebrile. Labs notable for primary cholestatic liver injury with conjugated hyperbilirubinemia to 8 and serum alkaline phosphatase 206. Leukocytosis to 10 with bandemia of 9%. Three sets of blood cultures from different sites growing Raoultella planticola. MR Cholangiography showed CBD dilation to 9 mm with numerous defects consistent with choledocholithiasis and acute ascending cholangitis. Patient underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy, and balloon sweep with complete stone removal confirmed on cholangiography. Rapid clinical recovery was seen after ERCP and IV antibiotics. Discussion: Raoultella planticola is a gram-negative bacillus, related to the genus Klebsiella. It is a rare cause of human infection, but now an emerging pathogen linked to fatal infections associated with soft tissue wound infections, cholangitis, Urinary tract infection, pneumonia, and conjunctivitis. There have been a few reported cases of R. planticola associated cholangitis, but typically seen in immunocompromised patients or those with recent invasive medical procedures. While age remained a common risk factor, our patient was otherwise healthy, immunocompetent, and with no prior surgeries making this pathogen an interesting source of infection. Given no other risk factors, the involvement of the biliary tract is suggestive of gut flora as a bacterial reservoir. Our patient recently emigrated from Ecuador and may have been exposed to contaminated water in the past. Our case highlights that this bacterium can cause severe infections in elderly patients who are otherwise healthy.