Wright State University Boonshoft School of Medicine Dayton, OH
Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure commonly performed to decompress portal venous pressure in patients with liver cirrhosis. Infection of TIPS, called endotipsitis, is a rare and underreported complication of the TIPS procedure. Bacteremia due to endotipsitis carries a mortality of 32%. It is a diagnosis of exclusion, as definitive diagnosis requires removal of TIPS and culture. There are only three reported cases of endotipsitis due to lactobacilli. Here, we present a rare case of endotipsitis due to Lactobacillus bacteremia.
Case Description/Methods: A 64-year-old female with a past medical history of nonalcoholic steatohepatitis (NASH), cirrhosis, portal hypertension, recurrent ascites, esophageal varices with bleeding, status post TIPS procedure 9 months ago who presented to the ED with fever, chills, somnolence, and progressive lethargy. Given concern for possible septic shock on presentation, a full infectious workup was performed including echocardiogram, ultrasound, and computed tomography of the abdomen and pelvis revealing a patent TIPS. Two sets of blood cultures grew Lactobacilli. She was started on broad spectrum antibiotics. Blood cultures were repeated on day 3, which showed no bacterial growth. Considering the history of TIPS and no other identifiable source of infection, a “probable” diagnosis of endotipsitis was made. The patient declined further inpatient work up; given her rapid clinical improvement, she was discharged on a 21-day course of IV piperacillin-tazobactam, based on culture sensitivities, with a plan to repeat blood cultures at that time.
Discussion: Sanyal et al. defined the term endotipsitis for the first time in 1998, indicating an infection of the TIPS procedure. A “definite” infection was referred to as a “continuous, clinically significant bacteremia, with vegetations or thrombi inside the TIPS, whereas a “probable” infection was described as “bacteremia in a patient with an apparently normal TIPS without an identified site of infection elsewhere in the body." However, there continues to be a lack of consensus on the definition of endotipsitis, resulting in unclear guidelines and the diagnosis becoming one of exclusion. It is imperative that clinical practice guidelines regarding definition and diagnosis be established. Definitive treatment of endotipsitis is removal of TIPS with liver transplantation, but given the clinical difficulty of this, it is often treated with antimicrobial agents.
