背景:经颈静脉肝内门体分流术(TIPS)支架感染是一种罕见且严重的并发症,最常见于TIPS创建和翻修期间。由于分流闭塞或植被,患者通常会出现复发性菌血症。迄今为止,报告了大约58例病例。我们介绍了一名在TIPS创建五年后被诊断为晚期多微生物TIPS感染的患者。
方法:一名63岁女性肝移植后复发性肝硬化和门脉高压症患者出现脓毒症和复发性超广谱β-内酰胺酶大肠杆菌菌血症。腹部计算机断层扫描显示TIPS闭塞,血栓延伸到右门静脉远端,盲肠和升结肠局灶性增厚。结肠镜检查显示这些区域的斑片状溃疡,组织病理学显示结肠粘膜溃疡伴纤维蛋白性渗出液。分流血栓切除和翻修显示出现感染的血栓。患者最初通过抗菌治疗和TIPS翻修来清除感染;然而,不久之后,她患有阴沟肠杆菌菌血症和光滑念珠菌和白色念珠菌真菌血症,并伴有复发性TIPS血栓形成。她无限期地继续接受抗真菌治疗,后来出现了耐万古霉素的屎肠球菌,并反复出现TIPS血栓。鉴于她的严重疾病和复杂的分流解剖结构,没有提供肝脏重新移植以去除感染的TIPS的选择。患者对利奈唑胺不耐受,并选择了临终关怀。
结论:临床医生应该意识到,在免疫功能低下的患者中,TIPS在TIPS产生后五年内可能会发生重复感染。
BACKGROUND: 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.
METHODS: 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.
CONCLUSIONS: Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.