Related Experiment Videos

Septic Pylephlebitis and Cavernous Transformation Presenting as Pyrexia of Unknown Origin: A Diagnostic Challenge

Aditi Sarker1, Prodipta Chowdhury2, Md Razibul Alam1

  • 1Department of Gastroenterology Bangabandhu Sheikh Mujib Medical University Dhaka Bangladesh.

Clinical Case Reports
|August 23, 2026
PubMed

Insights

Occult cholangitis can present as pyrexia of unknown origin (PUO) with liver enzyme changes. Early cross-sectional imaging is crucial for diagnosing this condition and preventing complications like portal vein thrombosis.

Area of Science:

  • Gastroenterology
  • Hepatology
  • Infectious Disease

Background:

  • Acute cholangitis typically presents with fever, jaundice, and RUQ pain.
  • Atypical or subacute cholangitis may manifest as pyrexia of unknown origin (PUO), delaying diagnosis and leading to vascular complications.
  • Non-cirrhotic portal hypertension with esophageal varices can be an indirect sign of underlying biliary pathology.

Purpose of the Study:

  • To highlight the importance of considering occult cholangitis in patients presenting with PUO and cholestatic liver biochemistry.
  • To emphasize the role of early cross-sectional biliary imaging in diagnosing occult cholangitis and associated pylephlebitis.
  • To illustrate the potential for severe vascular complications if occult cholangitis remains unrecognized.

Main Methods:

  • Case report of a 45-year-old man with PUO, weight loss, and suspected non-cirrhotic portal hypertension.
  • Detailed patient history, laboratory evaluation (including inflammatory markers and liver function tests), and serial imaging (ultrasonography, MRCP, contrast-enhanced CT).
  • Treatment involved intravenous antibiotics and anticoagulation.

Main Results:

  • The patient presented with PUO, elevated inflammatory markers, and a cholestatic-hepatitic liver enzyme pattern.
  • Initial ultrasonography was inconclusive, but subsequent MRCP and CT revealed biliary abnormalities, portal vein thrombosis, and signs of septic pylephlebitis and portal biliopathy secondary to occult cholangitis.
  • Treatment led to clinical improvement and partial portal vein recanalization.

Conclusions:

  • Occult cholangitis should be suspected in patients with PUO and cholestatic liver enzymes, even without classic biliary symptoms.
  • Early cross-sectional biliary imaging is vital for timely diagnosis of occult cholangitis and associated pylephlebitis.
  • Prompt recognition and treatment can prevent the development of chronic portal hypertensive and biliary sequelae.
Keywords:
cholangitisfever of unknown originportal biliopathyportal hypertensionportal vein thrombosispylephlebitis

Related Concept Videos

Acute Pyelonephritis II: Diagnostic Studies and Management01:28

Acute Pyelonephritis II: Diagnostic Studies and Management

Introduction:For diagnosing acute pyelonephritis, a comprehensive patient history is collected to identify symptoms such as dysuria, frequent or urgent urination, flank pain, or costovertebral angle (CVA) tenderness that may suggest a kidney infection.Physical ExaminationDuring the physical examination, CVA tenderness is assessed. This involves gentle percussion over the costovertebral angle, where tenderness often indicates a kidney infection.Diagnostic TestsUrinalysis: Used to identify white...
Acute Pyelonephritis I: Introduction01:27

Acute Pyelonephritis I: Introduction

Pyelonephritis is a bacterial infection that primarily affects the renal parenchyma and collecting system, including the renal pelvis, tubules, and interstitial tissue of one or both kidneys. It can be classified as either acute—a sudden, severe infection—or chronic, which refers to long-term or recurrent kidney infections.The primary cause of acute pyelonephritis (APN) is bacterial infection, with Escherichia coli accounting for approximately 70-80% of cases. Other bacteria, such as Proteus,...
Urinary Tract Infection II: Pathophysiology01:25

Urinary Tract Infection II: Pathophysiology

The pathophysiology of urinary tract infections (UTIs) encompasses several progressive stages, beginning with bacterial colonization and culminating in potential systemic complications if untreated. UTIs are primarily initiated by bacteria, such as Escherichia coli, which often originate from the gastrointestinal tract and migrate to the urinary system through the periurethral area. This migration can occur via several routes, including improper hygiene practices, sexual activity, or...
Atypical Pneumonia01:14

Atypical Pneumonia

Atypical pneumonia, often caused by Mycoplasma pneumoniae, is a form of pulmonary infection that differs from the classical presentation of bacterial pneumonia in both its cause and clinical symptoms. Mycoplasma pneumoniae is a pleomorphic bacterium notable for its lack of a rigid cell wall. This structural characteristic imparts resistance to beta-lactam antibiotics and significantly influences the bacterium’s behavior within the human host.Other pathogens responsible for the disease include...
Brain Abscess l: Introduction01:26

Brain Abscess l: Introduction

A brain abscess is a focal, intracerebral infection characterized by a localized collection of pus within the brain parenchyma, resulting from microbial invasion and the body’s inflammatory response. It progresses through stages: early and late cerebritis, followed by early and late capsule formation, reflecting tissue destruction, immune response, and eventual encapsulation.Etiology and PathogenesisCausative organisms vary with source and host factors, often involving polymicrobial infections,...
Streptococcal Pharyngitis01:27

Streptococcal Pharyngitis

Streptococcal pharyngitis, commonly known as “strep throat,” is an acute infection of the oropharyngeal tissues caused by the Gram‑positive Group A Streptococcus (Streptococcus pyogenes). Transmission occurs primarily through respiratory droplets expelled during coughing, sneezing, or talking.Mechanisms of Host Entry and Immune EvasionUpon entering the host, S. pyogenes adheres to the mucosal epithelial cells of the pharynx via surface proteins, notably lipoteichoic acid and the antiphagocytic...