Fever and Sepsis as an Unusual Complication of Erosion of an IVC Filter into the Duodenum

Abstract

Purpose: Erosion of an inferior vena cava (IVC) filter into the GI tract is rare. Similarly, fever and sepsis is an underappreciated complication of intravascular device migration. We report a patient with an unexpected duodenal-caval fistula detected endscopically as the postulated cause of unexplained recurrent sepsis. Case Report: A 67-year-old presented with one week of confusion. He denied abdominal complaints. He had been discharged 2 weeks earlier with Klebsiella pneumoniae sepsis. Past medical history was significant for multiple pulmonary emboli with placement of a non-retrievable IVC filter 2 years previously. Two months prior to the current admission, UGI endoscopy for Barrett's esophagitis screening lead to the seemingly incidental discovery of a thin, metallic foreign body protruding into the duodenum. On exam, temp. = 101.6°F, blood pressure = 140/80 without postural change, pulse = 74/min. Cardiac, pulmonary and abdominal exams were normal. WBC count = 16,000; 4 out of 4 blood cultures were positive for Staphylococcus aureas. Progressive dysphagia due to Parkinson's disease required percutaneous endoscopic gastrostomy tube placement. At UGI endoscopy, a thin metal wire was protruding through the wall of the second portion of the duodenum. A clean-based, non-bleeding ulcer was on the opposite wall. The finding was consistent with migration or erosion of a non-retrievable IVC filter through the duodenal wall. CT scan confirmed this finding. He declined further treatment. Discussion: Perforation of an IVC filter into the GI tract is rare. Other potential mechanisms of IVC-duodenal fistula are penetrating injury; erosion of tumor, abcess or pseudocyst. Clinical manifestations of filter migration into the duodenum are diverse, including chronic abdominal pain, GI bleeding of any magnitude, fever or sepsis. Clinical signs of infection, such as confusion in our patient, may be non-specific and misleading, mimicking more common disorders. Delay in diagnosis is common. We postulate that duodenal ulceration and sepsis were complications of an IVC filter. Fever and bacteremia are rare, reported complications of duodenal migration or perforation of these devices. Filter erosion should be considered in any patient with a history of filter placement and unexplained chronic abdominal pain, GI bleeding, fever or sepsis.