Cavernous Transformation of Portal Vein Due to Portal Vein Thrombophlebitis as a Sequelae of Steptococcus constellatus Bacteremia

Abstract

Cavernous Transformation of the Portal Vein is a rare complication of portal vein thrombosis or thrombophlebitis (PVT). Portal vein thrombophlebitis (pylephlebitis) is most commonly due to Bacteroides fragilis and Escherichia coli. PVT due to streptococcus constellatus bacteremia is very rare, with gastrointestinal tract being the most common source of infection. 53-year-old male who presented to the emergency room with complains of generalized abdominal pain, decreased appetite and chills on and off for 6 weeks. On examination he was hemodynamically stable, afebrile, but did endorse some epigastric and right upper quadrant pain without any rigidity or guarding. Laboratory studies were significant for an elevated white count at 18.6 and mildly elevated liver function tests AST 40, ALT 73, ALP 285 with normal total bilirubin, lipase. CT abdomen revealed portal vein thrombosis with cavernous transformation (Image 1) along with superior mesenteric vein thrombosis, prominent porto-caval and peri-pancreatic lymph nodes. Further imaging with MRCP did not reveal any biliary lesion. MRI liver protocol confirmed CT findings of portal vein thrombosis without evidence of intra hepatic or biliary mass or lesion. Blood cultures grew streptococcus constellatus and patient was started on intravenous antibiotics along with therapeutic anticoagulation. Echocardiogram done did not reveal any valvular vegetations. Patient clinically improved with the combination of antibiotics and anticoagulation. Repeat cultures were negative on day 4 of hospitalization and patient was discharge on oral antibiotic course for 4 weeks. Portal vein thrombophlebitis is a rare and serious condition which requires a high degree of index of suspicion. PVT due to streptococcus constellatus is much rare and typically manifests as liver abscesses or endocarditis. Our case is unusual as no source of infection was identified despite extensive workup. It is important to recognize this potential complication of portal vein thrombophlebitis as cavernous transformation of portal vein can lead to gastroesophageal variceal bleeding.Figure: CT coronal image showing cavernous transformation of portal vein with portal vein and superior mesenteric vein thrombosis.