A Rare Case of Endotipsitis with Multiorgan Involvement

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in the setting of portal hypertension and associated symptoms such as variceal bleeding. Infection of the TIPS, or Endotipsitis, is a condition being increasingly recognized. Endotipsitis has an estimated incidence of 1.5% and carries a very high mortality rate. However, there are no guidelines to manage this condition. Here we describe a case of endotipsitis with multiple causative organisms and complications involving several organs. A 41 yo male with history of autoimmune pancreatitis, biliary strictures, and portal hypertension with gastroesophageal varices underwent banding and a TIPS procedure complicated by thrombosis which required revision. He subsequently developed a polymicrobial bacteremia growing Enterobacter cloacae, Klebsiella pneumonia, and Enterococcus faecalis/faecium. TTE and CT Abdomen/Pelvis were negative. Patient was diagnosed with endotipsitis and discharged on a 6-week course of IV daptomycin and ertapenem. Two weeks later, he presented febrile (102°). He was otherwise asymptomatic. Blood cultures were positive for gram positive cocci. Fluid around TIPS was drained. Both blood cultures and the TIPS fluid cultures were growing Enterococcus faecium and Candida lusitaniae. He was also diagnosed with endocarditis by TTE and fungal chorioretinitis. He was to complete a 6-week course of ampicillin and ceftriaxone, fluconazole, and ciprofloxacin. Exact diagnostic criteria of endotipsitis are still being debated, though persistent bacteremia and fever without clear alternative source of infection following TIPS procedure is highly suggestive. Additionally, TIPS thrombosis, as demonstrated in our patient, is a strong risk factor for endotipsitis. As of mid-2017, approximately 56 cases of endotipsitis have been reported with a 32% mortality rate. A wide range of causative organisms have been documented. However, the most common organisms responsible for early endotipsitis (within 120 days) were gram positive bacteria, including staph and enterococci. Candida infections have been associated with the highest mortality at >60%. While anti-microbial agents are the mainstay of treatment, it is unclear how liver transplantation and chronic suppressive antibiotics fit into the long-term management. Given the increased identification of this condition, clinical practice guidelines for the diagnosis and management for endotipsitis are urgently needed.