Published online Apr 27, 2022. doi: 10.4254/wjh.v14.i4.846
Peer-review started: July 30, 2021
First decision: September 29, 2021
Revised: October 8, 2021
Accepted: March 25, 2022
Article in press: March 25, 2022
Published online: April 27, 2022
Processing time: 265 Days and 18.4 Hours
Infection of a transjugular intrahepatic portosystemic shunt (TIPS) stent is a rare and serious complication that most commonly occurs during TIPS creation and revision. Patients typically present with recurrent bacteremia due to shunt occlusion or vegetation. To date there are approximately 58 cases reported. We present a patient diagnosed with late polymicrobial TIPS infection five years following TIPS creation.
A 63-year-old female status-post liver transplant with recurrent cirrhosis and portal hypertension presented with sepsis and recurrent extended-spectrum beta-lactamase Escherichia coli bacteremia. Computed tomography of the abdomen revealed an occluded TIPS with thrombus extension into the distal right portal vein, and focal thickening of the cecum and ascending colon. Colonoscopy revealed patchy ulcers in these areas with histopathology demonstrating ulcerated colonic mucosa with fibrinopurulent exudate. Shunt thrombectomy and revision revealed infected-appearing thrombus. Patient initially cleared her infection with antibacterial therapy and TIPS revision; however, soon after, she developed Enterobacter cloacae bacteremia and Candida glabrata and C. albicans fungemia with recurrent TIPS thrombosis. She remained on antifungal therapy indefinitely and later developed vancomycin-resistant Enterococcus faecium with recurrent TIPS thrombosis. The option of liver re-transplant for removal of the infected TIPS was not offered given her critical illness and complex shunt anatomy. The patient became intolerant to linezolid and elected hospice care.
Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.
Core Tip: Polymicrobial transjugular intrahepatic portosystemic shunt (TIPS) infection may occur in an immunocompromised patient many years following TIPS creation. Given the high morbidity and mortality associated with TIPS infection, it is important to consider this diagnosis early in a patient with recurrent septicemia, even without recent TIPS creation or revision. Early shunt thrombectomy is important for source control and optimization of antibiotic penetrance of the TIPS.