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CASE SNIPPET
Year : 2011  |  Volume : 57  |  Issue : 2  |  Page : 134

Endotipsitis: A diagnostic challenge


1 Mount Sinai School of Medicine, New York, USA
2 Division of Liver Diseases, Mount Sinai Liver Cancer Program, Mount Sinai School of Medicine, New York, USA

Date of Web Publication4-Jun-2011

Correspondence Address:
S Aggarwal
Mount Sinai School of Medicine, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.81875

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How to cite this article:
Aggarwal S, Park J. Endotipsitis: A diagnostic challenge. J Postgrad Med 2011;57:134

How to cite this URL:
Aggarwal S, Park J. Endotipsitis: A diagnostic challenge. J Postgrad Med [serial online] 2011 [cited 2019 Nov 20];57:134. Available from: http://www.jpgmonline.com/text.asp?2011/57/2/134/81875


Transjugular intrahepatic portosystemic shunt (TIPS) is used commonly in various patients with cirrhosis. The current indications of using TIPS include acute variceal bleeding refractory to pharmacologic or endoscopic therapy, [1] and refractory ascites, hepatorenal syndrome, and hepatic hydrothorax. [2] Persistent infection of TIPS, known as "endoTIPSitis," is a rare but serious complication post-TIPS. [3]

A 52-year-old man with alcoholic cirrhosis underwent TIPS insertion in 2006 due to recurrent gastrointestinal bleeding. He had similar episodes in 2009 and received TIPS revision followed by uneventful hospital stay. He again presented with similar episodes when upper endoscopy revealed bleeding esophageal varix, which was banded. Doppler ultrasound showed partially occluded lumen of TIPS due to thrombosis. His TIPS was revised via transjugular route. The patient was initially well after the procedure. However, a week later he developed fever without any other significant complaint. Physical examination was remarkable for bilateral scleral icterus and oral temperature of 38.9°C without peripheral edema, asterixis, or abnormal heart/lung sound. Further workup showed elevated WBC count (20,000 cells/μL). No other laboratory values were changed significantly from baseline. Samples of blood, urine, and body fluid sent for culture revealed blood cultures positive for multiple drug-resistant (MDR) Klebsiella and after evaluating the sensitivity, the patient was started on tigecycline 25 mg i.v. twice a day. Extensive workup, including urine culture, transesophageal echocardiography, chest radiography, abdominal imaging, and diagnostic paracentesis, failed to localize the source of infection. Based on the time-frame of infection, partially occluded lumen of TIPS by thrombus serving as a potential nidus of infection, and no other simultaneous infection in hospital with similar agent ruled out nosocomial infection and helped us arrive at diagnosis of endotipsitis. [3] Monitoring of daily blood cultures found patient cleared of bacteremia after 9 days of therapy. The patient was discharged on oral doxycycline. The patient till date is fine without any subsequent fever or GI bleeds.

We, to the best of our knowledge, found 36 cases of endotipsitis reported till date [4] but none due to MDR Klebsiella. The "gold standard" diagnosis is removal of stent to identify it as a source of infection, possible only during liver transplantation or autopsy. According to the commonly used diagnostic criteria, [3] "definite infection" is defined as as clinically significant continuous bacteremia (fever and multiple positive blood cultures) along with vegetation or thrombi inside the TIPS and "probable infection" as sustained bacteremia and unremitting fever in patient with apparently normal TIPS without any other identifiable source of infection. Randomized study failed to prove any therapeutic advantage of prophylactic antibiotics in preventing early bacteremia after TIPS and also it contributes to the emergence of resistant strains among organisms. [5] Thus, use of prophylactic antibiotics should at best be avoided to prevent infections from drug-resistant organisms. Removal of shunt continues to be the "gold standard" treatment of endotipsitis; however, treatment is essentially medical therapy because TIPS is irremovable without liver transplantation. [4] Thus it is imperative for the physicians to have a high index of suspicion to diagnose it and avoid prophylactic antibiotics to prevent emergence of resistant strains.

 
 :: References Top

1.García-Pagán JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010;362:2370-9.  Back to cited text no. 1
    
2.Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: A critical update. Gut 2010;59:988-1000.  Back to cited text no. 2
    
3.Sanyal AJ, Reddy KR. Vegetative infection of transjugular intrahepatic portosystemic shunts. Gastroenterology 1998;115:110-5.  Back to cited text no. 3
    
4.Mizrahi M, Adar T, Shouval D, Bloom AI, Shibolet O. Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: Pathogenesis, clinical features and management. Liver Int 2010;30:175-83.  Back to cited text no. 4
    
5.Deibert P, Schwarz S, Olschewski M, Siegerstetter V, Blum HE, Rössle M. Risk factors and prevention of early infection after implantation or revision of transjugular intrahepatic portosystemic shunts: Results of a randomized study. Dig Dis Sci 1998;43:1708-13.  Back to cited text no. 5
    




 

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2004 - Journal of Postgraduate Medicine
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