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Published on: September 13, 2014
Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case
Irene Caridad Perez1, Ziv J Haskal2, John I Hogan3
1Department of Medicine, University of Virginia Medical Center, Charlottesville, VA 22903, United States.
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.
Insights
Late polymicrobial infection of a transjugular intrahepatic portosystemic shunt (TIPS) can occur years after placement. This case highlights the risk of recurrent infections and thrombosis in immunocompromised patients.
Area of Science:
- Hepatology
- Infectious Diseases
- Interventional Radiology
Background:
- Transjugular intrahepatic portosystemic shunt (TIPS) infection is a rare but serious complication.
- Most infections occur during TIPS creation or revision, presenting as recurrent bacteremia.
- This report details a unique case of late-onset, polymicrobial TIPS infection.
Observation:
- A liver transplant recipient with recurrent cirrhosis presented with sepsis and extended-spectrum beta-lactamase Escherichia coli bacteremia.
- Imaging revealed an occluded TIPS with thrombus and colonic inflammation.
- The patient experienced recurrent bacteremia and fungemia with multiple resistant organisms despite treatment and shunt revision.
Findings:
- The patient developed polymicrobial bacteremia and fungemia, including Enterobacter cloacae, Candida glabrata, C. albicans, and vancomycin-resistant Enterococcus faecium.
- Recurrent thrombosis of the TIPS occurred despite initial treatment and revision.
- The patient's complex condition and shunt anatomy precluded liver re-transplant.
Implications:
- Clinicians must consider late-onset TIPS superinfection, even up to five years post-creation.
- Immunocompromised status is a significant risk factor for developing severe, recurrent infections.
- Management of infected TIPS in complex cases remains challenging, with limited treatment options.
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