Torulopsis glabrata fungemia as a complication of a clotted transjugular intrahepatic portosystemic shunt

Late polymicrobial transjugular intrahepatic portosystemic shunt infection in a liver transplant patient: A case report

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.

CASE SUMMARY

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.

CONCLUSION

Clinicians should be aware that TIPS superinfection may occur as long as five years following TIPS creation in an immunocompromised patient.

Fungal endotipsitis: A case report and literature review

Endotipsitis is a broad term used to describe sustained and clinically significant bacteremia or fungemia from a suspected vegetation or thrombus within the transjugular intrahepatic portosytemic shunt (TIPS) device. Endotipsitis is a rare infection in post-TIPS patients and given the diagnostic challenges, there is a need to establish formal diagnostic criteria. Bacterial causes of endotipsitis have been well documented in the literature, but few fungal-associated etiologies have been published to date. With this paucity of data, treatment strategies are lacking regarding the role of antifungal duration, the aggressiveness of medical therapy, and the role of liver transplantation. We present a case of Candida-associated endotipsitis and suggest a need for preferred management strategies in an effort to decrease the significant morbidity and mortality of the infection.

Endotipsitis: A case report with a literature review on an emerging prosthetic related infection

AIM: To investigate the etiology and management of a poorly understood complication of transjugular intrahepatic portosystemic shunt; “endotipsitis”.

METHODS: A MEDLINE database search was carried out, reviewing all papers with specific words in the title or abstract, and excluding appropriately. Of 283 papers that were reviewed, 22 papers reporting 53 cases in total were included in the analyses.

RESULTS: No predominant etiology for endotipsitis was identified, but gram-positive organisms were more common among early-onset infections (P < 0.01). A higher mortality rate was associated with Staphylococcus aureus and Candida spp infections (P < 0.01). There was no trend in choice of antibiotic based on the microorganisms isolated and treatment varied from the guidelines of other vegetative prosthetic infections. In endotipsitis “high risk” organisms have been identified, emphasizing the importance of ensuring optimal antimicrobial therapy and adjunctive management strategies.

CONCLUSION: Higher mortality rate was associated with Staphylococcus aureus and Candida spp infections. A prospective multicenter trial is needed before specific treatment can be recommended.

Should stent-grafts replace bare stents for primary transjugular intrahepatic portosystemic shunts?

Transjugular intrahepatic portosystemic shunt (TIPS) creation using bare stents is a second-line treatment for complications of portal hypertension due in part to the relatively high number of reinterventions and the occurrence of new or worsened encephalopathy. Initially, custom-made stent-grafts were used for TIPS revision in cases of biliary fistulae. Subsequently, custom stent-grafts were used for de novo TIPS creation. With the introduction of the VIATORR(®) TIPS endoprosthesis a dedicated stent-graft became available for TIPS creation and revision. The VIATORR(®) demonstrated its efficacy and superiority to uncovered stents in retrospective analyses, case-matched analyses, and randomized studies. The improved patency of stent-grafts has led many to requestion the role of TIPS as a second-line therapy. Currently, randomized trials are warranted to redefine the role of TIPS in the treatment of complications of portal hypertension.

Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management

Transjugular intrahepatic portosystemic shunt (TIPS) is in widespread use for the decompression of portal pressure. The entity of persistent TIPS infection, also known as 'endotipsitis' is a rare but serious complication of TIPS insertion. The exact definition of 'endotipsitis' is still debated, but involves persistent bacteremia and fever together with either shunt occlusion, or vegetation, or bacteremia in the presence of a patent shunt, when other sources of bacteremia have been ruled out. To date, approximately 40 cases of 'endotipsitis' have been described, with predominance for male and alcoholic hepatitis patients. The clinical course is variable, but fever and chills are a constant feature. Bacteremia, can either occur early (<120 days) or late (>120 days) after stent insertion, with some cases occurring many years after the procedure. Although no predominant bacterial species have been described in 'endotipsitis', staphylococci and other Gram-positive bacteria are more commonly seen in early infection. The diagnosis of 'endotipsitis' is difficult and requires a high index of suspicion. A rigorous imaging work-up to rule out other sources of endovascular infection is usually required including ultrasonography, computed tomography and echocardiography. Because removal of the infected stent is impractical, treatment is empirical and based on a prolonged course of antibiotics. If eligible, some patients may be referred for liver transplantation. The use of prophylactic antibiotics during the initial TIPS procedure is controversial, and despite the lack of evidence, prophylaxis is the common practice. The aim of this review was to describe the definition, clinical course, diagnosis, pathogenesis, microbiology, treatment and outcome of endotipsitis.

Control of a Candida glabrata prosthetic endovascular infection with posaconazole

A 63-year-old man with a history of cirrhosis of the liver developed Candida glabrata fungemia after undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement. Treatment with oral fluconazole was initially effective, but when the patient became neutropenic, subsequent blood cultures grew C. glabrata and a thrombus developed, which partially occluded the stent. Despite treatment with fluconazole, blood cultures remained positive for C. glabrata. Treatment with posaconazole resulted in clinical improvement and the patient had only intermittently positive fungal cultures for 6 weeks. A CT scan showed resolution of the inferior vena cava thrombus. Subsequently, the patient developed hepatocellular carcinoma and hepatic encephalopathy and became noncompliant with posaconazole. Blood cultures again became positive for C. glabrata. The patient died a few weeks after the diagnosis of hepatocellular carcinoma, but the cause of death was believed to be worsening liver dysfunction, not C. glabrata infection. Posaconazole had controlled the infection for about 3 months prior to his death. In conclusion, posaconazole may be a useful option in the management of prosthetic endovascular infections caused by C. glabrata.

Torulopsis glabrata fungemia from infected transjugular intrahepatic portosystemic shunt stent

Transjugular intrahepatic portosystemic shunts (TIPS) are used to manage multiple complications of portal hypertension. Accounts of infection of TIPS stents are uncommon. The literature reports two cases of TIPS-associated Torulopsis glabrata (Candida glabrata) fungemia; both patients died within a year of TIPS placement despite therapy with intravenous antifungal agents. This report describes the successful long-term survival of a patient with Torulopsis TIPS stent infection.

Endotipsitis: an emerging prosthetic-related infection in patients with portal hypertension

The transjugular intrahepatic portosystemic shunt (TIPS) is an option for the treatment of portal hypertension. However, TIPS infection (endotipsitis) is distinctly uncommon. We report 3 new patients and review 23 published cases of endotipsitis. We calculate an incidence of 1.33% in patients undergoing the procedure. Twenty-three cases (88%) occurred more than a month after the procedure. The most common presentation included fever and primary bacteremia or fungemia. Gram-positive (18 cases), gram-negative microorganisms (10 cases), and fungi (3 cases) were the etiologic agents. Diagnosis may be difficult to establish, and new diagnostic criteria have been proposed. Twenty patients responded well to antibiotic treatment, and the 6 remaining patients died because of the infection. Endotipsitis is a new infectious disease to be considered in patients with a TIPS and bloodstream infection that is not clearly attributable to another source. Prolonged courses of antimicrobial agents can be curative, but liver transplantation is also an option to consider.

Infection of transjugular intrahepatic portosystemic shunt devices: three cases and a review of the literature

During the past decade, transjugular intrahepatic portosystemic shunting (TIPS) has become accepted as an alternative to the surgical shunt procedure for controlling the complications of portal hypertension, yet few data exist regarding infectious complications. The records of all patients who underwent a TIPS procedure during 1992-2000 at a single university teaching hospital were analyzed retrospectively to determine the rate and type of infections that occurred. A search of the English-language literature on the subject was conducted, and the findings were compared with our experience. Three cases of TIPS stent infection were identified out of 180 procedures performed during a 9-year period, resulting in an overall rate of infection of 1.7%. One of the patients was cured, and the other 2 died. A total of 21 cases of TIPS infection were identified from the literature search. A need exists for a standardized case definition for TIPS infection, and one is proposed.

Transjugular intrahepatic portosystemic shunts (TIPS): a decade later

Since the introduction of transjugular intrahepatic portosystemic shunt (TIPS) 10 years ago, it has been used increasingly in the management of portal hypertension and its complications. TIPS is now considered the procedure of choice for management of refractory variceal bleeding. Its role in the management of refractory ascites, hepatic hydrothorax, hepatorenal syndrome, and hepatopulmonary syndrome still awaits further prospective studies. The two main complications of TIPS are hepatic encephalopathy and shunt malfunction. Generally, TIPS stenosis or occlusion is a major drawback requiring routine surveillance of TIPS with doppler ultrasound. Venography with balloon dilation of the stent or placement of serial or parallel stents may be required in some cases. Promising modalities of preventing TIPS malfunction (e.g., brachy-therapy, covered stents, or anti-platelet derived growth factor) are currently being investigated.