Virginia Research Day 2021

Medical Resident Research Case Reports

17 Pylephlebitis From Liver Abscess Resulting in Streptococcus Viridans Bacteremia

Jacob LaGrone DO; Ryan O’Connell, DO Corresponding author: michael.moore1@LPNT.net

SOVAH Health Internal Medicine Residency Program

Context: Pylephlebitis or infective suppurative thrombosis of the portal vein usually starts with thrombophlebitis of smaller veins draining an area of infection leading to portal vein septic thrombophlebitis which can produce bacteremia. It typically presents with nonspecific abdominal pain/fevers and results in significant morbidity and mortality. Case Report: A 79-year-old African American female presented to the Emergency Department with suprapubic, non-radiating abdominal pain, nausea, fevers/chills, increased urinary frequency, and confusion with urinalysis concerning for a urine infection. She was admitted for urosepsis. Past Medical & Surgical History (Hx): Hypertension, hyperlipidemia, insulin dependent diabetes mellitus, and coronary artery bypass. Meds: Spironolactone 25 mg, atorvastatin 40 mg, furosemide 40 mg, lisinopril 20 mg, and pantoprazole 40 mg daily, plus metformin 500 mg and carvedilol 3.125 twice daily. Social and Family Hx: She was single and lived at home alone. Former smoker with 40+ pack years who denied alcohol or illicit drug use. Mother had coronary artery disease. P

ertinent Physical Exam Findings: BP 117/72, pulse 62, Resp 19, Temp 97.4°F, pulse ox 97% on 2L nasal cannula. She was missing all but 3 bottom teeth. Well healed midsternal surgical scar, no murmurs, mild suprapubic tenderness. Pertinent Lab: WBC 14,000, Hgb 12.2, eGFR 24, Cr 1.99, eGFR 27, and urinalysis with 21-50 wbcs, +4 leukocyte esterase, and 1+bacteria. Admission blood cultures grew streptococcus viridans. Urine culture had no growth. An abdominal/pelvic CT demonstrated hypodensities in the liver, and repeat (Hospital Day 3) CT imaging confirmed liver abscesses and a new finding of right portal vein thrombosis. Transthoracic echocardiogram was normal. Infectious Disease recommended drainage of the liver abscesses, but due to location this was impossible. Serial CT scans demonstrated significant decrease in size of liver abscesses over time but an extension of the portal vein thrombus into the distal mid portal vein with inflammatory change within the porta hepatis and head of pancreas. After 18 days of iv antibiotics, the patient was able to tolerate oral intake and ambulate. She was discharged home on 28 more days of iv Treatment: Intravenous (iv) ceftriaxone and metronidazole plus enoxaparin were begun.

ceftriaxone and metronidazole plus chronic oral apixaban. Diagnosis: Pylephlebitis with multiple liver abscesses and streptococcus viridans bacteremia. Comments: This case demonstrates that suppurative portal vein thrombosis can present with very non-specific abdominal complaints and fever which can be successfully managed if diagnosed early and aggressively treated. Conclusion: Pylephlebitis carries significant morbidity and mortality, but with prompt treatment outcomes can be promising. Imaging plays a critical role in establishing the diagnosis and etiology. Treatment must be immediate with broad spectrum antibiotics and systemic anticoagulation if there is evidence of thrombosis.

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