Klebsiella pneumoniae Liver Abscess, Endophthalmitis, and Meningitis in a Man with Newly Recognized Diabetes Mellitus

resolved. The dorsum of his right foot had only small, red macules, and erythema in the pretibial region had resolved. BCG vaccine has been used for decades for the prevention of tuberculosis. More recently, BCG has been used as immunotherapy for various tumors. Importantly, the dosing of BCG is much higher when given as cancer immunotherapy [5]. As a result, BCG immunotherapy is often complicated by systemic side effects. Although BCG has been recovered from blood immediately after subcutaneous injection [6], attempts at isolating the organism from skin specimens from patients with chronic cutaneous changes have been futile [7]. Therefore, the cause of the cutaneous granulomatous lesions has remained controversial. Even though some investigators have postulated a hypersensitivity reaction to BCG as the underlying etiology, others have pointed to the rapid response of patients to antituberculosis treatment as evidence for direct invasion [5]. To our knowledge, we report the first case of culture-proven BCG infection of a chronic cutaneous lesion. When combined with the granulomatous changes seen during pathological evaluation and an excellent clinical response to antituberculosis therapy, it appears that direct BCG infection is the etiology of at least some of the postimmunization cutaneous abnormalities in our patient. Stephen L. Moff, G. Ralph Corey, and Magnus Gottfredsson Department of Internal Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina