Perez IC, Haskal ZJ, Hogan JI, Argo CK. Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report. World J Hepatol 2022; 14(4): 846-853 [PMID: 35646273 DOI: 10.4254/wjh.v14.i4.846]
Corresponding Author of This Article
Curtis K Argo, MD, MS, Associate Professor, Doctor, Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, 1215 Lee St, Charlottesville, VA 22903, United States. cka3d@hscmail.mcc.virginia.edu
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Case Report
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Apr 27, 2022; 14(4): 846-853 Published online Apr 27, 2022. doi: 10.4254/wjh.v14.i4.846
Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report
Irene Caridad Perez, Ziv J Haskal, John I Hogan, Curtis K Argo
Irene Caridad Perez, Department of Medicine, University of Virginia Medical Center, Charlottesville, VA 22903, United States
Ziv J Haskal, Department of Radiology and Medical Imaging, Division of Vascular and Interventional Radiology, University of Virginia Medical Center, Charlottesville, VA 22903, United States
John I Hogan, Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, VA 22903, United States
Curtis K Argo, Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, VA 22903, United States
Author contributions: Perez IC was the internal medicine resident physician providing care during initial hospitalization; Perez IC also drafted and participated in the revision process and final submission of this manuscript; Haskal ZJ was the interventional radiologist that performed the procedures described in this case and participated in the whole revision process; Hogan JI was the infectious disease specialist overseeing her care and participated in the whole revision process; Argo CK was the outpatient and inpatient hepatologist who provided specialized care, participated in the revision process and final submission of this manuscript.
Informed consent statement: Consent was obtained verbally over the phone from the husband as the patient passed away.
Conflict-of-interest statement: Dr. Haskal disclosures include working with Varian, Boston Scientific, WL Gore and Associates, and Becton Dickinson. All other authors have no actual or potential conflicting interest in the submission of this manuscript.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Curtis K Argo, MD, MS, Associate Professor, Doctor, Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia Medical Center, 1215 Lee St, Charlottesville, VA 22903, United States. cka3d@hscmail.mcc.virginia.edu
Received: July 30, 2021 Peer-review started: July 30, 2021 First decision: September 29, 2021 Revised: October 8, 2021 Accepted: March 25, 2022 Article in press: March 25, 2022 Published online: April 27, 2022 Processing time: 265 Days and 18.4 Hours
Abstract
BACKGROUND
Infection of a transjugular intrahepatic portosystemic shunt (TIPS) stent is a rare and serious complication that most commonly occurs during TIPS creation and revision. Patients typically present with recurrent bacteremia due to shunt occlusion or vegetation. To date there are approximately 58 cases reported. We present a patient diagnosed with late polymicrobial TIPS infection five years following TIPS creation.
CASE SUMMARY
A 63-year-old female status-post liver transplant with recurrent cirrhosis and portal hypertension presented with sepsis and recurrent extended-spectrum beta-lactamase Escherichia coli bacteremia. Computed tomography of the abdomen revealed an occluded TIPS with thrombus extension into the distal right portal vein, and focal thickening of the cecum and ascending colon. Colonoscopy revealed patchy ulcers in these areas with histopathology demonstrating ulcerated colonic mucosa with fibrinopurulent exudate. Shunt thrombectomy and revision revealed infected-appearing thrombus. Patient initially cleared her infection with antibacterial therapy and TIPS revision; however, soon after, she developed Enterobacter cloacae bacteremia and Candida glabrata and C. albicans fungemia with recurrent TIPS thrombosis. She remained on antifungal therapy indefinitely and later developed vancomycin-resistant Enterococcus faecium with recurrent TIPS thrombosis. The option of liver re-transplant for removal of the infected TIPS was not offered given her critical illness and complex shunt anatomy. The patient became intolerant to linezolid and elected hospice care.
CONCLUSION
Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.
Core Tip: Polymicrobial transjugular intrahepatic portosystemic shunt (TIPS) infection may occur in an immunocompromised patient many years following TIPS creation. Given the high morbidity and mortality associated with TIPS infection, it is important to consider this diagnosis early in a patient with recurrent septicemia, even without recent TIPS creation or revision. Early shunt thrombectomy is important for source control and optimization of antibiotic penetrance of the TIPS.
