An unusual increase of D-dimer level-pylephlebitis caused by acute appendicitis: a case report

Acute appendicitis (AA) patients who present with a significantly increased level of D-dimer is not common. We speculated that the increase of D-dimer level was a result of pylephlebitis complication in the appendicitis patient. A 34-year-old man presented to the emergency department with sudden onset of lower quadrant abdomen pain. He was diagnosed with AA and scheduled for a laparoscopic appendectomy. He had a blood pressure of 80-90/30-40 mmHg, heart rate of 120-130/min, and his temperature was 38.3 °C. Routine blood test demonstrated a significantly elevated D-dimer (14,037 µg/L) with a negative blood gas test, normal ultrasound of the lower limbs, and normal pulmonary and abdominal computer tomography angiography (CTA) scans. Further tests showed a two-fold increase in D-dimer and abnormal hepatic function, indicating pylephlebitis, a rare but serious complication of AA. The patient was subjected to laparoscopic appendectomy, removing the cause of pylephlebitis, and received intravenous broad-spectrum antibiotics for an additional 1 week. The patient had clinical improvement with almost complete normalization of his D-dimer, white blood cell (WBC), alanine aminotransferase (ALT), aspartate aminotransferase (AST), fibrin degradation product (FDP) and platelet (PLT) levels. The patient was fully recovered and discharged from the hospital without any complications. Pylephlebitis secondary to AA is rare and can be easily missed. The unusual increase of D-dimer level provided critical value for pylephlebitis diagnosis.