Right-sided infective endocarditis is less common than left-sided endocarditis and can be a difficult clinical diagnosis. The presence of intracardiac devices is a major risk factor. The presentation is less clear than left-sided forms because of the presence of respiratory symptoms and the absence of systemic embolization. Pylephlebitis, or septic thrombosis of the portal vein, is a serious infectious condition that often delays diagnosis. It is a complication of intraabdominal or pelvic infections. Streptococcus gallolyticus (S. gallolyticus) can cause infective endocarditis and is associated with colon neoplasia and hepatobiliary disease. In this case report, we describe the case of a 76-year-old male with a history of rectal adenocarcinoma who presented with different episodes of fever of unknown origin (FUO), one of which occurred after pacemaker implantation. Ultimately, he was diagnosed with S. gallolyticus-mediated tricuspid valve endocarditis with underlying pylephlebitis. Investigations did not show evidence of pacemaker lead endocarditis.

Pylephlebitis, which is a type of septic thrombophlebitis of the portal vein, is a rare and life-threatening complication that commonly occurs following appendicitis. However, nonspecific abdominal complaints and fever can impede the diagnosis of pylephlebitis. Timely use of appropriate antibiotics and anticoagulants is paramount for treating this condition. We present a case of pylephlebitis and septic shock caused by acute nonperforated appendicitis. A 32-year-old man presented with migratory right lower abdominal pain. Blood cultures showed the presence of Escherichia coli. Blood test results showed increased bilirubin concentrations and coagulation factor abnormalities. A computed tomographic abdominal scan showed that the portal vein had a widened intrinsic diameter. After intensive care treatment with antibiotics, antishock therapy, anticoagulants, and other supportive treatments, the infection was monitored, the abdominal pain disappeared, and the jaundice subsided. Laparoscopic appendectomy was performed. Histopathology showed acute suppurative appendicitis, and no abnormalities were observed during the follow-up period after discharge. A multidisciplinary approach is mandatory for the decision-making process in the presence of pylephlebitis caused by appendicitis to obtain a correct diagnosis and prompt treatment. Similarly, the timing of appendectomy is important for minimizing intra- and postoperative complications.

BACKGROUND: Pylephlebitis, a rare and lethal form of portal venous septic thrombophlebitis, often arises from infections in regions drained by the portal vein. Herein, we report a case of peritonitis with portal vein thrombosis due to acute severe appendicitis, managed with intensive intraperitoneal drainage via open abdominal management (OAM).
METHODS: A 19-year-old male with severe appendicitis, liver abscesses, and portal vein thrombosis developed septic shock and multi-organ failure. After emergency interventions, the patient was admitted to the intensive care unit. Antibiotic treatment based on cultures revealing multidrug-resistant Escherichia coli and Bacteroides fragilis and anticoagulation therapy (using heparin and edoxaban) was initiated. Despite continuous antibiotic therapy, the laboratory results consistently showed elevated levels of inflammatory markers. On the 13th day, open abdominal irrigation was performed for infection control. Extensive intestinal edema precluded wound closure, necessitating open-abdominal management in the intensive care unit. Anticoagulation therapy was continued, and intra-abdominal washouts were performed every 5 days. On the 34th day, wound closure was achieved using the anterior rectus abdominis sheath turnover method. The patient recovered successfully and was discharged on the 81st day.
CONCLUSIONS: Alongside appropriate antibiotic selection, early surgical drainage and OAM are invaluable. This case underscores the potential of anticoagulation therapy in facilitating safe surgical procedures.

Portal vein thrombophlebitis is a rare complication that can occur in various hypercoagulable states, including COVID-19. We are presenting a 74-year-old female with a history of hypertension, diabetes, and lymphoma who contracted the COVID-19 infection and presented with persistent fever, leukocytosis, and mild epigastric tenderness. She developed hypotension, acute hypoxic respiratory failure, and worsening leukocytosis with bandemia and was diagnosed with portal vein thrombosis (PVT) and superior mesenteric vein thrombosis. The patient received broad-spectrum IV antibiotics and full anticoagulation therapy with heparin and was discharged on oral Warfarin after completing 14-day antibiotic therapy. She presented again with recurrent watery diarrhea, fever, abdominal pain, and fatigue and was diagnosed with pylephlebitis and multiple small liver abscesses. The patient was treated with antibiotics for six weeks and was discharged on warfarin, furosemide, and spironolactone with close outpatient follow-up. Prolonged fever in COVID-19 patients can indicate extensive thrombosis at unusual sites, which can lead to major morbidity and mortality in patients.

BACKGROUND: Pylephlebitis is an extremely rare form of septic thrombophlebitis involving the portal vein, carrying high rates of morbidity and mortality.
METHODS: We present a case of a 42-year-old male with no past medical history who presented with acute onset of abdominal pain and altered mental status with laboratory tests demonstrating new-onset acute liver failure. Pylephlebitis was determined to be the underlying etiology due to subsequent workup revealing polymicrobial gram-negative anaerobic bacteremia and complete thrombosis of the main and left portal veins. To our knowledge, this is the first documented case of acute liver failure as a potential life-threatening complication of pylephlebitis.
CONCLUSIONS: Our case highlights the importance of considering pylephlebitis in the broad differential for abdominal pain, especially if there are co-existing risk factors for hypercoagulability. We also demonstrate that fulminant hepatic failure in these patients can potentially be reversible with the immediate initiation of antibiotics and anticoagulation.

Extracolonic manifestations of Clostridium difficile have been rarely reported. We herein report a case of a 60-year-old immunocompetent man presenting with fever, nausea, abdominal pain, and loose stools for 2 weeks. Triple-phase liver computed tomography demonstrated pyogenic liver abscesses and portal pylephlebitis. Blood cultures grew C. difficile and Bacteroides fragilis, and liver abscess cultures grew Proteus mirabilis, Escherichia coli, and the viridans group Streptococci. Antibiotics coverage was selected to direct at all identified organisms. This demonstrates an unusual case of C. difficile bacteremia in a patient with polymicrobial pyogenic liver abscesses and pylephlebitis.

Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon but serious complication following an abdominal site of infection, most frequently diverticulitis or appendicitis. It has a high mortality rate, yet it commonly presents with unspecific abdominal complaints and fever, making diagnosis by clinical and laboratory examinations alone, impossible. This report highlights the extensive computed tomography (CT) findings of pylephlebitis with multiple hepatic abscesses thought to be secondary to diverticulitis, in a patient presenting with septic shock. Radiological characteristics differentiating the liver lesions from malignancy, and showing the ascending pathway of vascular involvement from the inferior mesenteric vein to portal veins is presented, as well as the search for the primary site of infection. Recognizing and understanding the imaging findings in pylephlebitis is crucial for diagnosis and avoiding delay of appropriate treatment for this otherwise often fatal condition.

Suppurative thrombophlebitis of the portal-mesenteric venous system occurring in the setting of abdominal inflammatory and infectious processes is a serious condition that can lead to septic shock, bowel ischemia, hepatic abscess, and death if unrecognized. Diagnosis is often delayed because symptoms are aspecific and pain at the primary site of infection may be mild. Contrast-enhanced CT scans can diagnose both portal thrombosis and a primary infection site. Treatment may include early resective surgery in case of appendicitis or diverticulitis, in association with large-spectrum antibiotics and possibly anticoagulation. A characteristic of suppurative thrombophlebitis, whether splanchnic or systemic, is the latency before the effects of antibiotic therapy are seen. Anticoagulation can be administered to avoid extension to the superior mesenteric vein. We presented a critically ill 53-year-old man with chronic colonic diverticulitis complicated by suppurative emphysematous portal-mesenteric thrombophlebitis with only a slow response to large-spectrum antibiotics.

A 90-year-old man presented with a 3-day history of general malaise. He was febrile (39.3°C) but the initial evaluation did not reveal the cause of the fever. After admission, Bacillus subtilis and Fusobacterium nucleatum were grown from multiple sets of blood cultures. In addition, contrast-enhanced computed tomography revealed thrombi in the portal vein and superior mesenteric vein; he was diagnosed with pylephlebitis. After receiving antimicrobial treatment and anticoagulation, the patient was cured. Pylephlebitis is a rare condition and may be the cause of unknown fevers. This is the first reported case of pylephlebitis caused by Bacillus subtilis.

Pylephlebitis is a rare but serious condition caused by intra-abdominal or pelvic infections that can lead to septic thrombophlebitis of the portal veins. While laparoscopic cholecystectomy is considered a safe and effective treatment option, it is not without its risks, and pylephlebitis following this procedure is an extremely rare occurrence. Here, we present the case of a 73-year-old male who presented with lower abdominal pain for the last two weeks. He had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis four weeks prior with an unremarkable follow-up. Laboratory tests revealed leukocytosis and blood culture showed Streptococcus constellatus. A CT scan revealed portal vein thrombosis causing diffuse periportal edema throughout the liver. The patient was treated with antibiotics and anticoagulation for pylephlebitis.