This patient was diagnosed to have severe Community-Acquired Pneumonia (CAP) due to P. aeruginosa, which was complicated by secondary hematogenous spread causing metastatic abscess in liver and spleen and MODS involving cardiovascular, hematologic and respiratory systems. Injury to thealveolar epithelium causes release of proinflammatory cytokines into the circulation which are ultimately responsiblefor septic shock. During treatment, she developed superadded secondary infection with Burkholderiacepacia. Pseudomonas aeruginosa is a gram-negative aerobic bacterium that causes several types of infections including wound, urinary tract, and respiratory tract infections. It is a common pathogenicbacteria in hospital acquired pneumonia, and is usually seen in patients who have structural lung disease, or are immunocompromised [1]. However, it is rarely identified as a cause of pneumonia in previously healthy individuals, accounting for 0.4–6.9% of the reported cases of CAP requiring hospitalization [2] and 1.8–8.3% CAP requiring Intensive Care Unit (ICU) admission [3]. Several studies [4,5] found that fatal P. aeruginosa pneumonia in healthy patients was associated with exposure to contaminated hot tubs. Harris et al.[6] reported a case of P. aeruginosapneumonia in a chronic asthmatic patient who was using a home humidifying device that contained water contaminated with P. aeruginosa.Other risk factors identified in various studies include bronchiectasis, cystic fibrosis, chronic heart failure, smoking, malnutrition and immunocompromised status [7]. Our patient was a home maker and there was no history of any of the above risk factors. Few studies have reported prior infection with Influenza A to be a risk factor for P. aeruginosa infection. Influenza viral infection causes respiratory epithelial cell dysfunction and apoptosis by disruption of protein synthesis and thus allowing increased bacterial adherence and invasion [1,8]. Occupational exposure in health care workers may also be a risk factor [9]. Our patient, prior to hospital admission, did not have any risk factor for pseudomonas infection. Compared to pneumonia caused by other pathogens,P. aeruginosa CAP runs a fulminant course, shows rapid dissemination and has poor prognosis[1].Semerci SYet al reported a case of hepatic and splenic abscess in a preterm infant caused by P.aeruginosa[11].Govan et al reported a case of a previously healthy 49-year-old man who died within 12 hoursofhospital admission. P. aeruginosa was subsequently isolated both from sputum and blood samples taken at the time of admission and from postmortem specimens of his lung, liver and spleen [2,12].

In a review of literature by Hatchette et al from 1966 to 2000, he reported 11 cases of P aeruoginosa[10]. Further Maharaj S et al did a review of nine cases indexed in PubMed from 2001to 2016 of which 3 were complicated by sepsis with MODS [2]. However, none of these cases were complicated by metastatic abscess formation.Predilection for the Right Upper Lobe (RUL) was seen in two-thirds of the cases of P. aeruginosaCAP described by Hatchette et al[10] and in 7 out of 9 cases by Maharaj S et al [2]. P. aeruginosais an aerobic bacterium and upper lobes provide a more favorable environment due to higher ventilation to perfusion ratios [2]. However, our patient had bilateral, multifocal involvement with cavitation in CT thorax while the chest radiograph initially showed only left mid zone involvement. As P.aeruoginosa is an invasive pathogen, and causes thrombotic endarteritis, pneumonia rapidly progresses to necrosis, with coalescing of these foci into cavities. Surprisingly the total leucocyte count was normal on admission, despite the fact that the infection was disseminated. However, there was neutrophilic leukocytosis with toxic granules seen in the neutrophils and CRP was very high suggestive of bacterial infection.Later, she went to develop neutropenic sepsis. The leucocyte count may be variable (high, normal or low) as reported by Hatchette et al [10].The current guidelines from the Infectious Diseases Societyof America(IDSA) suggest that patients with CAP who are hospitalizedin the ICU and or have risk factors like structural lung diseases, immunocompromised status, prior use of antibiotics before admission, should receive a macrolide or a fluoroquinoloneplus cefotaxime or ceftriaxone or a beta-lactam–beta-lactamase inhibitor [13].Our patient was treated as per the protocol for treatment of pseudomonas pneumonia with antipseudomonal antibiotic(piperacillin-tazobactum and clarithromycin which was escalated to meropenem, clarithromycin and co-trimoxazole), considering the possibility of emergence of resistant strains during the therapy. This was also in accordance with the antibiotic sensitivity pattern. Though earlier studies showed better prognosis in younger patients, ourpatient unfortunately did not respond to the treatment.

cepacia is a member of a group known as B. cepacia complex which includes nine differentrecognized genomovars. It is a gram-negative, glucose-non-fermenting, aerobic bacillus and causes acute systemic infection and “cepacia syndrome” which is progressive necrotizing pneumonia [14].It is associated with infections in patients with underlying lung disease, like cystic fibrosis, chronic granulomatous disease, immunocompromised individuals, hospitalized patients and drug addicts [15].Outbreaks may occur due to contaminated antiseptics, disinfectants, ventilators and other types of medical equipment [14]. Also, person-to-person spread has also been documented.In a study by Bressler et al, among ICU patients without cystic fibrosis, bacteremia due to B. cepacia was associated with renal failure requiring dialysis, recent abdominal surgery, bronchoscopies, tracheostomy, and presence of a central line [16]. In a study by Huang et al, most patients had seriouscomorbidities including diabetes mellitus, Chronic Obstructive Pulmonary Disease (COPD), malignancy and congestive heart failure [15]. Our patient had central line insertion and was transferred to Intensive Care Unit (ICU). She,thus having two risk factors.The organism was sensitive to meropenem and co-trimoxazole. As she had overwhelming infection, resulting in metastatic infection in liver, splenic and renal infection, she succumbed to her illness.To our knowledge, this is the first report of pseudomonas pneumonia complicated by metastatic abscesses (liver, spleen and kidney), secondary infection with B. cepacia and MODS.