PUNCTURE FROM A TOOTHPICK: AN ATYPICAL PRESENTATION OF PYLEPHLEBITIS

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Septic thrombophlebitis comprises of a spectrum of venous thrombi arising as a sequelae of inflammation in the setting of bacteremia. Pylephlebitis describes a septic thrombophlebitis involving the portal vein. We report a unique case of pylephlebitis resulting from endovascular foreign body perforation of the gastric wall. CASE PRESENTATION: A 69 year old female presented to our Emergency Department with 1 week of progressive abdominal pain, bloating and anorexia complaining of dark stools. She was noted to have sepsis and was started on broad spectrum antibiotics. Workup for sepsis revealed gastric antral thickening (Figure 1). Subsequent esophagogastroduodenoscopy (EGD) showed a toothpick perforating the gastric antral wall (Figure 2). Despite of removal, she continued to have abdominal pain and fever, prompting repeat CT abdomen. It showed infected portal venous, superior mesenteric venous (SMV) thrombus and portal venous gas (Figure 3). Blood cultures grew Streptococcus anginosus and Rothia mucilaginosa. Despite appropriate antibiotics, she developed septic shock and DIC, prompting another CT abdomen revealing a 1.4 cm abscess adjacent to the left anterolateral aspect of the SMV, thrombosis of the left portal vein with extensive portal venous air in the left lobe consistent with septic thrombophlebitis of the superior mesenteric vein and portal venous system (Figure 4). She was taken to OR for exploratory laparotomy, repair of gastric perforation, abdominal abscess drainage, portal vein thrombolysis. She was started on anticoagulation and was given extended course of antibiotic therapy at discharge. DISCUSSION: Pylephlebitis describes a septic thrombophlebitis involving the portal vein. The etiology of pylephlebitis is the pathophysiologic development of localized pockets of inflammation as an humoral immune response to an infection. Thrombophlebitis in small veins either embolize or extend into larger downstream veins, coalescing into the apogee of a portal vein thrombosis. While most cases involve thrombosis involving the SMV (42%), involvement of intrahepatic branches of the portal vein (39%) and the splenic vein (12%) is common. Pylephlebitis may arise from intra-abdominal or pelvic infection through direct downstream sequelae caught in the portal system. While of cases of pylephlebitis occur more commonly in the setting of diverticulitis, pylephlebitis remains a rare complication. Due to the paucity of data regarding pylephlebitis, it is difficult to assert that there is any greater association with extragastric complications when compared to other abdominal disease states. Gastric perforation from tooth pick with secondary pylephlebitis is a very unique clinical presentation. On review of available literature, only one case similar case was found. CONCLUSIONS: Physicians should have a high index of suspicion in cases of intra-abdominal pathology who remain unstable. Reference #1: Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804. Reference #2: Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114. Reference #3: Peters, Thomas G., et al. “Suppurative Pylephlebitis Caused by Toothpick Perforation.” Southern Medical Journal 1988; 81:414-415. https://doi.org/10.1097/00007611-198803000-00034. DISCLOSURES: No relevant relationships by Krishna Akella, source=Web Response No relevant relationships by Brian Boden, source=Web Response No relevant relationships by Rajeev Fernando, source=Admin input No relevant relationships by Steve Georgopoulos, source=Admin input No relevant relationships by Kashif Hussain, source=Web Response No relevant relationships by Najia Hussain, source=Web Response No relevant relationships by Samer Ibrahim, source=Web Response No relevant relationships by ahsan khan, source=Web Response No relevant relationships by Paul Poidomani, source=Web Response No relevant relationships by Richard Ricca, source=Web Response No relevant relationships by Howard Sklarek, source=Web Response No relevant relationships by Amanda Stashin, source=Web Response