Vegetative infection of transjugular intrahepatic portosystemic shunts

The occurrence of and the clinical picture of infection of transjugular intrahepatic portosystemic shunts (TIPS) has not been described previously. We describe the clinical features, associated pathogens, results of treatment of a previously unreported complication of TIPS, and primary infection of TIPS occurring after formation of the neointima.

Patients with TIPS and fever were evaluated to exclude other sources of infection. The diagnosis was based on the occurrence of fever with positive blood cultures and either a thrombus or vegetations on the stent or persistent bacteremia in a patient with a TIPS and no other detectable source of infection despite an extensive search.

Eight patients met diagnostic criteria. Two of 8 cases occurred within 10 days of TIPS manipulation despite antibiotic administration before the procedure. The clinical features included fever (8 patients), tender hepatomegaly (5 of 8), hypoxemia (2 of 8), septic pulmonary emboli (1 of 8), septic shock (2 of 8), neutrophilia (5 of 8), and subsequent development of necrotizing fasciitis (1 of 8). Blood cultures were positive in all cases. The organisms included oral and enteric aerobic gram-negative bacteria in 7 of 8 patients and Candida in 1 patient. All 8 responded to administration of antibiotics. Two patients died of myocardial infarction and alcoholic hepatitis, respectively.

Infective endotipsitis is an uncommon complication of TIPS. Recognition of its clinical features will facilitate diagnosis. Most patients responded to antibiotic therapy.