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Title : A 63 year-old male w/ fever & chill
Date : April 16, 2010
Contributed by

Kyung Mok Sohn, MD
Division of Infectious Diseases, Chungnam University Hospital, Korea

Patient History
Age/Sex 63 yrs old / Male
Chief complaint Fever and Chill
Present illness

A 63-year-old male patient admitted to our hospital with a 5-day history of fever, chill. The patient was in his usual state of health until 5 days before admission. He complained of genralized body aches but no other symptoms. He took NSAID for 3 days before admission but it did not work at all.

Past medical history

He underwent right total hip replacement arthroplasty due to AVN 3 years ago. He has been known to have alcoholic liver cirrhosis (Child-Pugh B) since 2009.

Physical examination

revealed no remarkable findings.

Initial laboratory findings

BP : 130/72 mmHg HR : 115/min RR : 24/min BT : 38.8 \'C

Radiologic findings



 
Question - ID Case of the Week ( April 16, 2010 )
What are the most likely diagnosis and causative microorganism ?
 
Correct Answer

Pylephlebitis

 

-         Blood culture : E. coli

-         Inciting infection : Colitis, right side

 
Review

Definition

          infective suppurative thombosis of portal venous system

Etiology

         It is a rare complication of ruptured viscera-including appendicitis & diverticulitis

         The most common inciting infection was appendicitis

         One of the frequent foci currently is diverticulitis

         Maybe more common in patients with hypercoagulable states

         The superior mesenteric vein was involved in 15 of 44 patients (34%) in one case series

Micobiology

          Bacteremia ocuured 88% of cases of one series

          The most common blood stream isolates were B. fragilis and E. coli

          Usaually polymicrobial

          Enterecocci are uncommon

Diagnosis

         Abdominal pain and fever are the most common presenting symptoms

         Like liver abscess, patients may have minimal or no clinical features

         The key to the diagnosis is a high index of suspicion

         Ultrasonography sensitivity 70-90% specificity 99%

         Invasive angiographic technic - direct portal venography

         Non-invasive technic - CT, MRA

Treatment

         Antibiotic therapy TOC

    - Metronidazole plus cefotaxime or ceftriaxone or ciprofloxacin

       - Piperacillin/tazobactam or ampcillin/sulbactam or carbapenems

       - Duration of therapy at least 4~6 weeks

         Surgery is not usually required

         Anticoagulation

- There are no RCT studies and no consensus

Anticoagularion can be considered in following conditions

-          Progression of thrombus

-          Persistent fever unresposive to antibiotic therapy

-          If patiens have hypercoagulable state (e.g. malignancy, clotting factor deficiency)

-          If Bacteroides is isolated

-          If there is mesenteric vein involvement

Complications

         Liver abscess

         Progression of thrombus to mesenteric vein and bowel ischemia

         Portal hypertension

Prognosis

         Mortality rate of 11-32%

      Intraabdominal sepsis, pre-existing liver disease, abdominal surgery à 50%

         Short term - bowel infarction, ischemia

         Long term - portal hypertension

 

 


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