Pylephlebitis in a Previously Healthy Emergency Department Patient with Appendicitis
The patient, a 27-year-old Hispanic male with no past medical or surgical history, presented to the emergency department (ED) with a chief complaint of fevers, chills and intermittent epigastric pain for 5 days. He stated that this pain started acutely, 30 minutes after eating dinner (steak and beans), was burning in quality, non-radiating and lasted approximately 20 minutes. This pain recurred several times over multiple days. Two days prior to arrival in the ED, the patient began experiencing subjective fevers and chills. He also reported having a single episode of vomiting, but denied diarrhea, sick contacts, recent travel, dysuria, hematuria, chest pain or shortness of breath.\nOn the initial physical exam the patient was found to be tachycardic (122 beats per minute), but afebrile (98.2°F) and relatively normotensive (106/59 mmHg). He was diaphoretic, but otherwise in no significant distress. His skin was mildly jaundiced and his sclera was icteric. His lungs were clear to ausculation and his cardiac exam was negative for murmurs, rubs, or gallops. His extremities were within normal limits, with no evidence of edema or rash. The patient was mildly tender in the epigastrium, but his abdomen was soft and non-distended. He had no rebound tenderness, no involuntary guarding, no Rovsing’s, Obturator or Murphy’s signs. The remainder of his abdomen was non-tender. Labs were significant for a leukocytosis of 16,000 with toxic granulations and a neutrophilic predominance. The patient was thrombocytopenic with a platelet count of 20,000/μL. His D-dimer and fibrinogen were elevated at 1428 mg/dl and 864 mg/dl, respectively. Finally, his liver function tests revealed an elevated total biliruben of 2.9 mg/dL and an elevated alkaline phosphatase of 278. The patient also received a chest radiograph and electrocardiogram, which were free of abnormalities.\nThe patient was treated for severe sepsis vs. septic shock. He received multiple boluses of normal saline, in addition to broad-spectrum antibiotics to cover for a suspected intra-abdominal infection. The patient responded well to these interventions, his vital signs began to normalize, and he stated that he was feeling better.\nAn abdominal ultrasound was ordered for further evaluation, given the patient’s epigastric pain and abnormal liver function tests. On this study, the liver appeared normal, with no intra- or extra-hepatic ductal dilatation. The kidneys, aorta, spleen and pancreas all appeared within normal limits. The gallbladder contained no stones or sludge, but the gallbladder wall was mildly thickened at 5mm. There was no evidence of peri-cholecystic fluid.\nAt this time, a surgical consult was placed for evaluation of possible acute cholecystitis/cholangitis. During his evaluation, the surgeon found no tenderness or distension on physical exam, but noted the abnormal lab findings, as well as the gallbladder wall thickening on ultrasound. He stated that it might have been an atypical case of acute cholecystitis, but given the constellation of abnormal lab values, he recommended a computed tomography (CT) of the abdomen/ pelvis and further medical workup.\nThe patient was subsequently admitted to the medical intensive care unit for continued antibiotic therapy and diagnostics. In addition to a standard infectious workup, the patient received testing for a variety of multi-systemic infections including influenza, viral hepatitis, HIV, malaria and tularemia. On hospital day 2, 2 of the 4 blood cultures grew E. coli. The patient’s antibiotics were tailored for more specific therapy and a CT of the abdomen and pelvis was obtained on hospital day 3. A preliminary report noted a dilated and thick walled retrocecal appendix with adjacent inflammation and free fluid, consistent with acute appendicitis. The radiologist noted inflammation of the gallbladder wall, but suspected that this was secondary to the adjacent inflamed appendix.\nOn hospital day 4, the final CT abdomen/pelvis read was submitted, which confirmed the diagnosis of appendicitis, and also noted small, branching, hypodense, tubular lucencies in the right lobe of the liver consistent with pylephlebitis (). The patient was subsequently taken to the operating room for a laproscopic appendectomy. The procedure was performed without complications. Intravenous antibiotics were continued until hospital day 6 when the patient was discharged. There was no mention of pylephlebitis in the primary team notes, or in the surgical consult notes. Antibiotics were discontinued upon discharge, despite an elevated white blood cell count of 15.1 × 103/μL (16.1 ×103/μL on admission). The patient’s total bilirubin remained elevated as well (3.0 mg/dL), compared to his admission value of 2.9 mg/dL.\nOne week later, the patient was seen in surgery clinic. He stated that he was feeling better, with minimal pain at the surgery site, and that he was able to eat and drink without issue. His staples were removed and he was told to return as needed. He was then lost to follow up.