Popliteal Artery Embolism in Abdominal Aortal Thrombus with Liver Abscesses Caused by Heterozygous Prothrombin Mutation with Protein S Deficiency and Factor VIII Elevation

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We report on a 64-year-old woman who was admitted to a peripheral hospital with known cholecystolithiasis complicated by acute abdominal pain. Her past medical history included pulmonary embolism and deep vein thrombosis (DVT) 3 years ago, arterial hypertension and obesity. The following day, laparoscopic cholecystectomy was performed because of gallbladder hydrops. Postoperatively, she complained of progressive right-sided abdominal pain. A CT scan was performed 2 weeks postoperatively showing multiple hepatic and splenic abscesses as well as rightsided thoracic effusion. Furthermore, an extensive aortal thrombus of about 10 cm above the coeliac trunc was visible without radiological signs of dissection or infection. Intravenous therapeutical heparinization was started aiming at an anti Xa level of around 0.6 U/ml. During the following days, further CT scans revealed progressive liver necrosis, and severe impairment of liver function developed necessitating transfer to ICU. The patient was transferred to our hospital and directly admitted to the intensive care unit on day 42. She presented in poor general condition with confusion, severe dyspnea and sepsis without signs of shock. Biochemistry showed signs of systemic infection (leucocytosis of 62000/μl, C-reactive protein of 230 mg/l), a disturbed liver function with signs of hepatocellular necrosis (prothrombin time 50%, cholinesterase 2.4 kU/l, AST 750 U/l) and impaired respiratory parameters (blood gas analysis under oxygen administration of 8 l/min: pO2 63, pH 7.46, lactate 3.4 mmol/l). Imaging procedures (ultrasound, CT scan) confirmed the aortal thrombus, extensive hepatic and splenic abscesses and a right-sided thoracic empyema as well as basal pneumonia. Immediate therapy with a total of three percutaneous thoracic and hepatic abscess drainages was initiated under ultrasound-guidance. In addition to other germs (Enterococcus faecalis, Candida spp.), a multiresistant strain (Enterobacter cloacae) was detected in cultures taken from the drainages. Therefore, quadruple antibiotic therapy was administered. The hepatic drainages rested in place (with several changes) for several months. Internal drainage by a stent placed by ERCP was ineffective, the stent had to be removed by a second ERCP. During these months, several problems complicated the clinical course (relapse of thoracic empyema necessitating repeated thoracic drainage, severe episodes of arterial hypertension, recurrent AV-reentry tachycardia, repeated vomiting, symptomatic transitory psychotic syndrome).