Case Presentation: 56 male with a history of hypertension, recurrent UTIs, and diverticulitis presented with 4 days of fever, chills, malaise, dizziness, and progressive dyspnea. He denied bowel changes, nausea, or vomiting. He was admitted for severe sepsis secondary to diverticulitis, with notable labs of lactic acidosis (3.8 mmol/L), AKI (creatinine 2.16 mg/dL), leukocytosis (17,400 WBC/μL), hyperbilirubinemia (2.5 mg/dL), and transaminitis. Blood cultures grew E. coli, and Biofire GI panel detected E. coli and Bacteroides fragilis. Initial CT abdomen/pelvis with contrast showed acute diverticulitis with portal venous gas. Despite broad-spectrum antibiotics (vancomycin & piperacillin-tazobactam), clinical worsening with persistent leukocytosis, hyperbilirubinemia, and acute onset jaundice prompted further imaging. MRCP showed mild gallbladder distention, mild perihepatic and perisplenic ascites, portal and retroperitoneal lymphadenopathy. Repeat CT revealed extensive mesenteric vein thrombosis (MVT) and inflammation consistent with pylephlebitis but no abscess or perforation. Surgery, GI, and ID were consulted, and conservative care was continued. Antibiotics were broadened to IV Ertapenem for 4 weeks. Oral anticoagulation was initiated. Follow-up included weekly labs and post-resolution colonoscopy.
Discussion: Pylephlebitis, defined as portal vein infective suppurative thrombophlebitis, occurs in areas of portal venous circulation draining abdominal and pelvic infections. Acute diverticulitis and appendicitis are the most common infections associated with pylephlebitis with most common pathogens including Escherichia coli, Bacteroides spp., and Streptococcus spp. This rare condition has an incidence of 0.37-2.7 cases per 100,000 person-years and a high mortality rate of 14% [4]. Here, we reported a unique case of sepsis secondary to acute diverticulitis complicated by E.coli bacteremia, MVT, and pylephlebitis. Untreated pylephlebitis can progress to abdominal infarction causing serious negative patient outcomes. Repeat imaging was critical for diagnosis when clinical deterioration occurred. Sepsis induces a prothrombotic state and progressive abdominal infection contributed to thrombosis despite appropriate DVT prophylaxis [6]. Other causes of prothrombotic states like malignancy, trauma, and underlying hypercoagulable conditions, should be ruled out [5]. Early initiation of broad-spectrum antibiotics, with aerobic, anaerobic, and gram-negative bacilli coverage, is critical [4]. Imaging, including abdominal ultrasound or CT abdomen, can provide adequate diagnosis, though sensitivity of both modalities remains unclear. Initiation of anticoagulation is not required in all patients with pylephlebitis but has become more common in practice. Anticoagulation should be started in patients with progression of thrombosis on repeat imaging or consistent fevers despite appropriate antibiotic therapy [4].
Conclusions: This report highlights the importance of promptly identifying a rare complication, pylephlebitis, in setting of abdominal/pelvic infections. A multidisciplinary approach facilitated quick diagnosis and treatment, underscoring the necessity of broad-spectrum antibiotics and anticoagulation therapy to prevent further complications like bowel infarction. Early imaging played a critical role in diagnosis and prevention of further consequences of the pathology.