Virginia Research Day 2021

PYLEPHLEBITIS FROM LIVER ABSCESS RESULTING IN STREPTOCOCCUS VIRIDANS BACTEREMIA Jacob LaGrone, DO, Ryan O’Connell, DO Sovah Health Internal Medicine Residency Program, Danville, VA

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Clinical Course : Intravenous (iv) ceftriaxone and metronidazole plus enoxaparin were begun. 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 pancreas head( Figure 3 a & B). After 18 days of iv antibiotics, he was able to take oral intake and ambulate. Discharge home was after 4 weeks of iv ceftriaxone and metronidazole plus chronic oral apixaban. Discussion: 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. Treatment includes antibiotics and anticoagulation. The diagnosis of pylephlebitis requires the demonstration of portal vein thrombosis usually accompanied by bacteremia in a febrile patient. CT scan imaging is best for identifying the underlying focus of infection elsewhere within the abdomen or pelvis. hypodensities in the liver and repeat (Hospital Day 3) CT imaging confirmed liver abscesses and a new finding of right portal vein thrombosis (Figure 21 & b.. Transthoracic echocardiogram was normal and repeat CT imaging prior to discharge (Hospital day 12) Pertinent Diagnostic Studies (Day of ICU Admission): WBC 14,000, Hgb 12.2, eGFR 24, Cr 1.99, 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

Background: Pylephlebitis or infective suppurative thrombosis of the portal vein usually starts with thrombophlebitis of smaller veins draining an area of infection which leads to portal vein septic thrombophlebitis which can produce bacteremia. It typically presents with nonspecific abdominal pain/fevers and results in significant morbidity and mortality. Chief Complaint & History : 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 a urinalysis concerning for a urine infection. She was admitted for urosepsis. Past Medical History: Hypertension, hyperlipidemia, non-insulin dependent diabetes mellitus and coronary artery bypass Medications : Spironolactone, Atorvastatin, Furosemide, Lisinopril, Metformin, Pantoprazole and Carvedilol Allergies: No known drug allergies Family History : Father deceased with no known medical history. Mother had coronary artery disease Pertinent Positive Review of Systems : Suprapubic, non-radiating abdominal pain, nausea, fevers/chills, increased urinary frequency and confusion Vital Signs: T: 97.4 F; P: 62; BP: 117/72; RR 19; Oxygen sat 97% on 2 liters Pertinent Physical Findings (Day of Admission) : Missing all but 3 bottom teeth. Well healed midsternal surgical scar, no murmurs and mild suprapubic tenderness. Social History: Lives alone and performs activities of daily living without difficulty. Former smoker with 40+ pack year history, and denies alcohol and illicit drug use

L ive r

Spleen

Figure 2: Abdominal CT Scan with Right Hepatic Lobe liver abscess (Arrow) but no right portal vein thrombosis

Pancreas

Figure 2..Repeat CT with improvement in liver abscess & worsening right portal vein thrombosis (Yellow Arrow).

Conclusion: Pylephlebitis has high morbidity and mortality. Appropriate imaging and prompt treatment including broad spectrum antibiotics and systemic anticoagulation, if there is evidence of thrombosis, are needed for an optimal outcome. References: 1. Plemmons RM, et al. Septic thrombophlebitis of the portal vein (pylephlebitis): Diagnosis and Management in the Modern Era . Clin Infectious Dis. 1995; 21:1114. 2. Choudhry AJ,, et al. Pylephlebitis: a Review of 95 Cases. J Gastroint Surgery 2016; 20:656. 3. Duffy FJ , et al. Suppurative Pylephlebitis and Pylethrombosis: the Role of Anticoagulation. Am J Surg 1995; 61:1041.

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