LAUSR

Dear Editor, A 74-year-old diabetic male patient presented with a 15-day history of abdominal pains and episodes of fever. Laboratory findings included leukocytosis and discretely increased C-reactive protein, as well as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) at the upper limits of normality. Noncontrast-enhanced computed tomography (CT) of the abdomen showed signs suggestive of an inflammatory process with sigmoid diverticulosis (Figure 1A). The patient presented clinical worsening, was unresponsive to antibiotic therapy, and evolved to jaundice in one day. Additional laboratory tests showed increases in leukocytosis, C-reactive protein, AST, ALT, and total bilirubin. A blood culture showed growth of Citrobacter spp., Streptococcus spp., and Klebsiella spp. A contrast-enhanced CT scan of the abdomen demonstrated thrombi and gas in the portal venous system (Figure 1B), spleno-mesenteric junction (Figure 1C) and inferior mesenteric vein (Figure 1D). Subtotal colectomy was performed, and the pathology study confirmed an acute inflammatory process with sigmoid diverticulosis and an incidental finding of a small cecal adenocarcinoma. The antibiotics were changed, and parenteral anticoagulation was started. The patient evolved to clinical improvement, being discharged after one month. Pylephlebitis, which is characterized by septic thrombosis of the portal vein or its branches, has an annual incidence of 0.37–2.7 cases per 100,000 inhabitants per year. It occurs in 0.16% of patients with intra-abdominal infections. It typically affects individuals between 40 and 65 years of age, and 60– 70% of the affected individuals are male. The main causes include diverticulitis (in 19–30% of cases), pancreatitis (in 5–31%), appendicitis (in 2–19%), infections of the biliary tract (in 3–14%), and inflammatory bowel disease (in 2–6%), as well as umbilical catheterization and omphalitis in neonates. Risk factors for pylephlebitis include the following: a history of surgery, seen in 29–37% of patients; smoking, seen in 29%; malignancies, seen in 6–17%; immunosuppression, seen in 14%; blood dyscrasias; alcoholism; and steroid use. The clinical presentation of pylephlebitis is nonspecific, common symptoms being fever, abdominal pain, nausea, diarrhea, and anorexia; however, a presentation of jaundice accompanied by fever and abdominal pain should raise the suspicion of the disease. Laboratory findings include leukocytosis (in 80% of cases), positive culture in blood or tissues (in 44–88%), elevated liver enzymes (in 40–69%), and total bilirubin (in 55%). From cultures, a single microorganism is isolated in 47% of cases and multiple microorganisms are isolated in 44%, the most common being anaerobic, gram-negative bacteria. The pathogens typically identified include Escherichia coli, Streptococcus spp., Bacteroides spp., Proteus spp., Klebsiella spp., and Enterobacter spp.. In patients with pylephlebitis, Doppler ultrasound is useful for the characterization of thrombi, portal vein ectasia, collateral venous networks, hepatosplenomegaly, and ascites. The diagnostic method of choice is intravenous contrast-enhanced CT,