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

Abstract

Torulopsis glabrata fungemia developed in a patient with a clotted transjugular intrahepatic portosystemic shunt (TIPS) 11 months after placement. Fungemia persisted despite treatment with amphotericin B. On autopsy, T. glabrata was found in the thrombus occluding the TIPS and extending into the splenic and portal vein. TIPS infections may be considered in patients with fungemia. Copyright 1998 by the American Association for the Study of Liver Diseases T orulopsis glabrata (Candida glabrata) is considered to be a saprophyte of humans and to be of limited pathogenicity. 1 Under conditions of altered resistance, this yeast can become pathogenic. 2 We report a patient with T. glabrata fungemia from a clotted transjugular intrahepatic portosystemic shunt (TIPS) that was seeded with yeast. Case ReportA 55-year-old man with end-stage liver disease secondary to cryptogenic cirrhosis underwent TIPS for recurrent variceal bleeding. Two revisions for stent occlusion were done over the next 6 months while he awaited liver transplantation. He was admitted 11 months after TIPS placement with right upper quadrant pain and fever. Evaluation included a right upper quadrant ultrasound that showed a thick-walled gallbladder with cholelithiasis, no ductal dilatation or TIPS flow, bilirubin of 24 mg/dL (direct 15), and alkaline phosphatase of 43 U/L. Broad-spectrum antibiotic therapy was begun, and the patient underwent endoscopic retrograde cholangiopancreatography that showed no common duct stones. Blood cultures drawn 7 days after admission grew T. glabrata. Amphotericin B was started, and the patient underwent cholecystectomy.Complications during hospitalization included a perioperative myocardial infarction and renal failure. Despite 26 days of amphotericin therapy (total, 1,950 mg) and additional flucytosine, multiple blood cultures remained positive for T. glabrata. A transthoracic cardiac echo showed no vegetations. The patient was transferred to our hospital and died on day 27 after the initial admission. On autopsy, T. glabrata was found in thrombus that occluded the TIPS and extended into the splenic and portal vein with no other sites of infection or thrombus found.

Should Stent-Grafts Replace Bare Stents for Primary Transjugular Intrahepatic Portosystemic Shunts?

“…The term ''definite endotipsitis'' was coined for continuous bacteremia with an observed vegetation or thrombus in the TIPS stent, while ''probable endotipsitis'' refers to persistent bacteremia and fever with an apparently normal stent and no other obvious source of infection. 53,54 A variety of organisms have been isolated from such cases, including gram-negative enteric pathogens, Staphylococcus aureus, and enterococci and also fungal TIPS stent infections, [55][56][57] the latter as all other infections potentially lethal with sepsis and multiorgan failure. There were no special reports on increased incidence of endotipsitis after VIATORR 1 endoprosthesis placement.…”

Fungal endotipsitis: A case report and literature review

“…Notably, Candida infections , as compared to bacterial infections, have been associated with the highest mortality (>60%) . Only four prior cases of Candida ‐associated endotipsitis have been documented in the literature, of which only one responded to antifungal treatment (Table ) . While the role of prophylactic antibiotics has been studied in post‐TIPS patients, no study has yet to evaluate prophylactic antifungal therapy in post‐operative TIPS patients.…”

Control of aCandida glabrataprosthetic endovascular infection with posaconazole

“…Most reported TIPS infections have been attributed to enteric bacteria [5,7 Á9]; however, three cases of TIPS infection caused by Candida species have been reported [5,6,10]. Two fatal cases involved Candida glabrata fungemia that was unsuccessfully managed with fluconazole/5-flucytosine and amphotericin B treatment regimens.…”

“…Two fatal cases involved Candida glabrata fungemia that was unsuccessfully managed with fluconazole/5-flucytosine and amphotericin B treatment regimens. Autopsies revealed that the TIPS were occluded with organized thrombi containing numerous yeast organisms [6,10]. A third case involved a patient with a thrombotic TIPS who was infected with fluconazole-sensitive Candida albicans [5].…”