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Abstract

INTRODUCTION

Pylephlebitis, defined as suppurative thrombosis of the portal vein often associated with bacteremia, is a rare and serious complication of intra-abdominal infections. Prior to antibiotics, the mortality rate of this disease approached 100%.1 The veins adjacent to the infection are the first to be involved, with later spread to the portal vein and possibly the mesenteric and splenic veins.2-3 Extension into the mesenteric veins can lead to bowel necrosis and increased morbidity and mortality.2-4

CASE PRESENTATION

A 63-year old male with a history of hypertension presented to the emergency department with one week of progressively worsening malaise, chills, severe fatigue, and right upper quadrant abdominal pain. He was tachycardic with a heart rate of 120 and hypotensive to 70/30 mm Hg. Exam revealed a mildly distended abdomen with tenderness to palpation in the right upper quadrant and right lower quadrant. Laboratory studies were significant for a leukocytosis with bandemia and an elevation of the total bilirubin and alkaline phosphatase. Abdominal CT scan showed mucosal thickening involving the rectosigmoid colon. Nodular rounded lesions containing bubbles of air, concerning for multiple abscesses, ran the length of the recto-sigmoid colon and extended into the mesentery. A thrombus was noted in the main portal vein and superior mesenteric vein. There was heterogeneity in the left hepatic lobe consistent with multiple hepatic abscesses. Of note, the patient had a recent colonoscopy showing multiple sigmoid diverticulae. He was started on broadspectrum antibiotics with vancomycin and piperacillintazobactam. He briefly required vasopressor support. A heparin drip was also started to manage the portal vein and superior mesenteric vein thrombosis. Blood cultures eventually grew group C streptococcus, and vancomycin was discontinued per the susceptibility pattern. The patient was treated in the hospital for 14 days and was discharged on oral amoxicillin-clavulanic acid for 14 additional days. During his stay, the patient was bridged to warfarin with a goal INR of 2-3.

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