Critical Care |

Pylephlebitis: An Uncommon and Dangerous Cause of Right Upper Quadrant Pain FREE TO VIEW

Timothy Ori, MD; John Sherner, MD
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Walter Reed National Military Medical Center, Bethesda, MD

Chest. 2013;144(4_MeetingAbstracts):285A. doi:10.1378/chest.1704898
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Pylephlebitis, septic thrombophlebitis of the portal vein, is an uncommon yet severe complication of bacteremia secondary to intra-abdominal and pelvic infections. The non-specific presentation and low incidence makes recognition challenging, yet relatively high morbidity and mortality rates make diagnosis and treatment critical.

CASE PRESENTATION: Our patient is a 61 year old male with a history of diverticular bleed presenting with a 10 day history of fever, nausea and vomiting. 4 days earlier, he presented with similar symptoms and was diagnosed with suspected viral gastroenteritis. The patient was unresponsive to symptomatic therapy however, and he returned upon developing rigors and anorexia. At presentation, the patient was febrile while all other vital signs were normal. Laboratory evaluation revealed leukocytosis, elevated AST, ALT, and alkaline phosphatase, and hypokalemia and hyponatremia. Blood cultures drawn during the previous presentation confirmed Bacteroides fragilis bacteremia. Abdominal computed tomography demonstrated heterogeneous hepatic parenchyma and a left portal vein thrombus, confirmed on PET imaging. Antibiotic therapy with pipercillin-tazobactam, and anticoagulation therapy with intravenous heparin, was initiated. The patient remained intermittently febrile with rigors for 72 hours before clinical improvement was evident. After a two week hospitalization, during which the fever and abdominal discomfort resolved, the patient was transitioned to oral therapies. He completed 6 weeks of antibiotic therapy and 3 months of anticoagulation without evidence of recurrence.

DISCUSSION: While pylephlebitis remains a relatively uncommon diagnosis, early recognition in the critical care setting is imperative to successful outcomes as clinical response to therapy may take several days. Diverticulitis and appendicitis remain the most commonly associated infections, though no etiology was identified here. Fever and abdominal discomfort are hallmarks of the non-specific presentation, and leukocytosis, transaminitis and elevated alkaline phosphatase are routinely seen as in this case. Treatment consists of prolonged parenteral antibiotics covering both gram negative enteric organisms and anaerobes, and while there is no clear consensus regarding the role of anticoagulation, this patient was treated successfully.

CONCLUSIONS: We present a case of B. fragilis pylephlebitis, initially suspected to be common gastroenteritis, treated successfully with targeted antibiotic therapy and anticoagulation.

Reference #1: Plemmons RM, Dooley DP, Longfield RN: Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995, 21:1114-1120.

Reference #2: Baril N, Wren S, Radin R, Ralls P, Stain S. The role of anticoagulation in pylephlebitis. Am J Surg 1996; 172: 449-452

DISCLOSURE: The following authors have nothing to disclose: Timothy Ori, John Sherner

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