Septic pulmonary embolism originated from subcutaneous abscess after living donor liver transplantation: a pitfall of postoperative management
A 49-year-old male underwent LDLT because of primary sclerosing cholangitis. Preoperative performance score was 1 and the model for end-stage liver disease score was 24.8. The patient had a history of total colectomy because of ulcerative colitis. The donor was the patient’s wife, and the blood types were identical. A right hemiliver graft was used. Graft size was 750 g and the ratio of graft volume/standard liver volume of the recipient was 52.1 %. The cold and warm ischemic time was 111 and 56 min, respectively. Duct-to-duct anastomosis was adopted for biliary reconstruction because postoperative management of strictures is easy to perform by endoscopic methods. Splenectomy was also performed because of preoperative thrombocytopenia resulting from splenomegaly. Expected amount of bleeding was 29,876 ml. He was treated with tacrolimus, mycophenolate mofetil, and steroids as immunosuppressants. The whole-blood trough level of tacrolimus was adjusted to 10–12 ng/ml during the first postoperative week, and was tapered thereafter. The mycophenolate mofetil doses ranged from 500 to 1,000 mg/day. Methylprednisolone (700 mg) was administered twice intraoperatively, tapered gradually thereafter, and discontinued on postoperative day (POD) 35. The patient was discharged on POD 40.\nHe was re-admitted on POD 48 because of severe acute cellular rejection. After three courses of steroid pulse therapy using methylprednisolone (each comprising 500 mg per session for 3 days; total dose of 4.5 g of methylprednisolone) were performed, the liver dysfunction gradually improved (Fig. ); however, continuous peripheral intravenous drip infusion therapy via the left forearm was necessary for 20 days because of appetite loss. The patient was discharged on POD 83; however, he visited our hospital on POD 87 complaining of pyrexia accompanying pain in the left forearm. Laboratory results showed a peripheral white blood cell count of 4,000/mm3 with 22.0 % stab cells, C-reactive protein (CRP) levels of 10.3 mg/dl and albumin level of 2.4 g/dl. Liver function tests, including alanine aminotransferase (ALT) measurements, were almost within the normal range (Fig. ). Rubefaction accompanying the subcutaneous abscess was present at a wound on the left forearm formed by intravenous drip therapy during the last hospital stay (Fig. ). Although respiratory symptoms were not present and performance status was zero, chest computed tomography (CT) revealed five pieces of cavitary or wedge-shaped nodules in the periphery of the bilateral lung (Fig. ). The lung nodules ranged from 0.8−2 cm in diameter, and were indistinct on a chest X-ray. β-d glucan levels were <6.0 pg/ml, Aspergillus antigens were not detected and mycobacterial culture of sputum was negative. The smear from the incisional drainage of the skin, blood and sputum revealed the presence of Gram-positive coccus; empiric broad-spectrum intravenous antibiotics using vancomycin (2 g/day) were thus started immediately. Lastly, methicillin-sensitive Staphylococcus aureus was cultured both from the blood and the subcutaneous abscess of the left forearm.\nThe pathogenesis was diagnosed as SPE secondary to S. aureus septicemia originating from the subcutaneous abscess of the left forearm. Vancomycin was de-escalated to cefazolin (6 g/day) for 11 days following cefaclor treatment (1.5 g/day) for 4 days with drainage of the subcutaneous abscess. The patient showed a good response to the antibiotic therapy; blood cultures detected no bacteria, the subcutaneous abscess in the left forearm epithelized, and the lung cavitary lesions disappeared by 141 days after LDLT.