THE ZEBRA OR THE HORSE: CHALLENGES IN DIAGNOSING PYLEPHLEBITIS J. Marston; R. Thibodaux Department of Internal Medicine, LSU Health Sciences Center - Baton Rouge Introduction: non-cirrhotic portal vein thrombosis is an uncommon condition which usually presents with abdominal pain as well as small volume ascites. While most cases are related to an underlying hypercoagulable state, it can also be associated with intraabdominal inflammatory conditions such as Acute pancreatitis, cholecystitis, appendicitis and diverticulitis. This case illustrates the difficulty of diagnosing pylephlebitis and the high degree of suspicion often required for diagnosis. Case: A 59 year old woman with CAD presented to the ED with RUQ abdominal pain for the past five days. She reported associated chills, dyspnea, nausea and emesis. On exam, she exhibited only mild right upper quadrant tenderness. Labs revealed mild leukocytosis, transaminitis, AKI, elevated alkaline phosphatase, and mild normocytic anemia. Abdominal CT scan revealed thrombosis of the intrahepaticportionof therightportalvein and anticoagulation initiated for acute non-cirrhotic portal vein thrombosis. She denied any personal or family history of thrombotic events, and a work up for hypercoagulable states including APLA, PNH, JAK-2 mutation was negative. She clinically improved and was discharged on rivaroxaban. She represented to the ED five days later complaining of subjective fever, chills, dyspnea, and near syncope, requiring a brief stay in the ICU as her blood pressure and heart rate remained labile despite aggressive volume resuscitation and empiric antibiotics. Given her symptoms along with persistently elevated transaminases and alkaline phosphatase, MRCP was obtained which revealed the previously identified portal vein thrombosis but suggested pylephlebitis with hepatic microabscesses. She clinically improved after modification of her antibiotics and remained hemodynamically stable with resolution of her transaminitis. Rivaroxaban was discontinued, and she was discharged to complete an extended course of antibiotics.
Discussion: Pylephlebitis, or infective suppurative thrombosis of the portal vein, is an uncommon complication of primary intraabdominal infection, occasionally with the source of infection being unapparent as in our case. It results from thrombophlebitis of surrounding small veins at the site of infection which ultimately propagates to involve the portal vein. Although pylephlebitis is a rare clinical entity, abdominal pain and fever are frequently encountered clinical symptoms. Modern imaging and microbiologic techniques have improved the detection rate of pylephlebitis, yet morbidity remains high. Therefore, prompt diagnosis and treatment is essential. Anticoagulation is recommended in certain circumstances. Clinicians should remain vigilant in suspecting the unusual while treating the usual.
cell transplantation were canceled as patient started to develop hepatic failure and renal failure, and became too weak to continue with the treatment plan. After discussion with the patient and his family, a decision was made to initiate hospice in accordance to patient’s wishes. Literature review revealed only a handful of cases with B-cell lymphoma presenting as acute Discussion: pancreatitis. This case is even more unique in that despite it being a Stage 1A lesion, the cancer initially responded to treatment, however recurred and ultimately resulted in the death of the patient.
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