Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature.

We describe the cases of 2 patients who had septic thrombophlebitis and were successfully managed with endovascular thrombectomy. Patient A developed septic thrombophlebitis of the inferior vena cava after several retroperitoneal resections for metastatic renal cell carcinoma. The thrombus was successfully removed via endovascular mechanical balloon thrombectomy. Patient B was a patient with pancreatic adenocarcinoma involving the portal vein who developed a septic inferior vena cava thrombus extending from the level and beyond the renal veins, for which she underwent endovascular thrombectomy. We argue that this approach is safe and feasible. It should be considered as a supplemental treatment modality for select decompensating patients who require lifesaving interventions and have contraindications to traditional management of surgical thrombectomy or excision of the involved venous segment.

Donor-Derived Candida dubliniensis Resulting in Perigraft Abscesses in a Liver Transplant Recipient Proven by Whole Genome Sequencing: A Case Report.

BACKGROUND: The transmission of fungi via transplant, although well-known, has not often been molecularly proven. We describe a case of donor-derived candidiasis verified by whole genome sequencing. CASE DESCRIPTION: The multiorgan donor was a 42-year-old woman with subdural hemorrhage. Procurement of the thoracic organs was performed followed by the abdominal organs. Tissue from the left bronchus grew Candida dubliniensis. The liver recipient was a 63-year-old woman with cryptogenic liver cirrhosis. She was noted to have worsening leukocytosis on postoperative day (POD) 9. Computed tomography of the abdomen and pelvis showed multiple rim-enhancing collections around the graft. Percutaneous drainage was performed. Fluid cultures grew C dubliniensis. C dubliniensis isolated from the donor's left bronchus and the liver recipient's abscesses were verified to be related by whole genome sequencing. We postulate that C dubliniensis colonizing the donor's transected trachea could have contaminated the inferior vena cava when the former was left open after explant of the donor's lungs. A portion of the donor's contaminated inferior vena cava was transplanted along with the liver graft, resulting in the infected collections in the recipient. CONCLUSIONS: Our case report highlights the importance of maintaining a sterile field during organ procurement, especially in a multiorgan donor whose organs are explanted in succession.

Invasive pulmonary aspergillosis presenting as thoracic mass causing obstruction of the superior and inferior vena cava in an immunocompetent patient: a diagnostic dilemma.

Invasive pulmonary aspergillosis (IPA) is a disease of immunocompromised patients, but its prevalence is increasing in immunocompetent persons. Patients usually present with non-specific symptoms, sometimes consistent with bronchopneumonia. We discuss the case of a 19-year-old boy who presented with constitutional respiratory symptoms along with signs of obstruction of the superior and inferior vena cava. A chest radiograph was suggestive of a thoracic mass raising suspicion of bronchogenic carcinoma/ benign mass, sarcoidosis and tuberculosis, but a diagnosis of invasive aspergillosis was established. The patient showed excellent clinico-radiological improvement with administration of voriconazole. Invasive pulmonary aspergillosis may also present with atypical findings and should be considered in differentials when investigating a case even if the patient does not have a risk factor.

Inferior Vena Cava Stent-Graft Sepsis.

We present the case of a patient with a complicated medical history, which included stent grafting as a life-saving measure for an iatrogenic inferior vena cava (IVC) injury. For persistent sepsis secondary to stent-graft infection, the patient underwent extraction of 2 IVC stent grafts, primary repair of a duodenal-caval fistula, and repair of the IVC with an allograft vein patch. Discussion of this case sought to shed light on the intricacies involved in medical decision making in an era of advanced medical technology.

Endovascular repair of a Streptococcus pneumonia-induced aortitis complicated by an iliacocaval fistula.

PURPOSE: To describe the successful endovascular treatment and follow-up of a patient with a Streptococcus pneumonia-induced right iliacocaval fistula. CASE REPORT: A 82-year-old man was diagnosed with a right iliacocaval fistula, as a result of Streptococcus pneumoniae infection of the distal aorta and proximal right common iliac artery. After antibiotic treatment, he was initially unsuccessfully treated with balloon expandable covered stents. Then, the fistula was excluded by an aortamonoiliac endograft to the left common iliac artery, and occluders in the distal and proximal right common iliac artery followed by a femoral-femoral crossover bypass. Postoperatively patient was treated with prolonged antibiotics. After a follow-up of 20 months, there are no signs of active infection, endoleak, or fistula, both clinically and on 2-deoxy-2-[F18]fluoro-D-glucose positron emission tomography/computed tomography. CONCLUSION: In selected patients, complicated infectious disease of the aorto-iliac tract may be treated successfully with an endograft and prolonged antibiotics.

Successful percutaneous thrombectomy of an infected vena-caval thrombus due to a toothpick.

We report a case of a 25-year-old Caucasian female with a septic thrombosis in the inferior vena cava (IVC) which contained a toothpick. She was admitted with fever and abdominal pain for 2 weeks. Computed tomography scan showed thrombus with air density in the suprarenal IVC. However, there was no evidence of duodenocaval fistula. Because of the patient's reluctance for surgery, endovascular therapy was tried. A partially-deployed nitinol stent was used as a filter, and aspiration thrombectomy was performed. Unexpectedly, a toothpick was retrieved within the stent. Anticoagulants and antibiotics were administered. A follow-up computed tomography after 2 months showed total resolution of the residual thrombus.

Fungal endocarditis of the eustachian valve in carcinoid heart disease: a case report.

The case is presented of a fungal-origin endocarditis affecting the eustachian valve. During surgery for pulmonary and tricuspid valve replacement, a 54-year-old male with carcinoid disease was found to have a 3-cm vegetation attached to the eustachian valve. Histopathological assessment of the vegetation revealed the presence of Candida species. The patient made a good postoperative recovery and was continued on a three-month course of antifungal therapy.

Eustachian valve endocarditis: a rare localization of right side endocarditis. A case report and review of the literature.

BACKGROUND: Right-sided endocarditis occurs predominantly in intravenous drug users, in patients with pacemaker or central venous lines and in patients with congenital heart disease. The vast majority of cases involve the tricuspid valve. Eustachian valve endocarditis is an uncommon disease with similar signs and symptoms of the tricuspid valve endocarditis. A series of only 16 cases of eustachian valve endocarditis are reported in the literature. CASE PRESENTATION: We present a case of a 25-year old woman with intravenous drug abuse who had a staphylococcus aureus tricuspid valve endocarditis associated to eustachian valve endocarditis. Transthoracic echocardiography, as first line examination, showed the vegetations on tricuspid and eustachian valve. CONCLUSION: Our case describe an unusual location of right side endocarditis in a intravenous drug abuser. In our case, in accord with other cases described in the literature, transthoracic echocardiography disclosed eustachian valve endocarditis. Antimicrobial management is not altered by the recognition of eustachian valve endocarditis. Antibiotic treatment and duration of eustachian endocarditis depends on the isolated organism and is similar to antibiotic therapy used in native valve endocarditis.

[Vascular Aspergillus infection in two recipients of kidneys from the same donor]. / Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante.

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracranial tumour. A benign ganglioma was shown in biopsy. The two recipients received the same immunosuppressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosuppression. The A patient was a 53-year-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised for sciatic pain refractory to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. It was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-year-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection, so she was kept on immunosuppressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solid-liquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was performed in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysms. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered, requiring haemodialysis.

Infección vascular por Aspergillus en dos receptores de injertos renal del mismo donante / Vascular aspergillus infection in two renal recipients from the same donor

El caso clínico aquí descrito es el de dos pacientes que recibieron un injerto renal procedente del mismo donante, una mujer de 39 años fallecida a consecuencia de un tumor cerebral benigno. Los dos receptores iniciaron tratamiento inmunosupresor con ciclosporina A, esteroides y basiliximab, manteniéndose posteriormente con ciclosporina A y esteroides. La paciente A, una mujer de 53 años, padecía una insuficiencia renal crónica terminal (IRCT) secundaria a pielonefritis crónica, llevando en el momento del trasplante cinco años en programa de hemodiálisis. A los 35 días post-trasplante comenzó con clínica de ciatalgia derecha homolateral al injerto, refractaria a tratamiento analgésico. El día 37, presentó deterioro de la función renal que fue interpretado como un episodio de rechazo agudo y tratado como tal. Al mismo tiempo refirió parestesias con frialdad y disminución del pulso arterial periférico en la pierna derecha. Se le realizó una resonancia magnética donde se apreció la existencia de un pseudoaneurisma en la arteria ilíaca con una fístula arteriovenosa a cava inferior, que posteriormente fue confirmado mediante la realización de arteriografía. La paciente B, se trata de una mujer de 56 años, con IRCT secundaria a pielonefritis crónica en hemodiálisis previa durante 2 años. En el cuarto mes posttrasplante presentó un deterioro de la función renal. Se descartó la existencia de rechazo agudo mediante la realización de biopsia renal, manteniéndose el mismo tratamiento inmunosupresor. Debido al deterioro de la función renal, la paciente volvió a programa de hemodiálisis. Al sexto mes, desarrolló un cuadro de parestesias, frialdad y disminución del pulso arterial periférico en la pierna derecha homolateral al injerto. Mediante ecografía se apreció ectasia renal y una masa adyacente. Se realizó una tomografía que confirmó la existencia de una masa sólido-líquida. Mediante arteriografía se identificó como un pseudoaneurisma. En los dos casos se realizó nefrectomía del injerto, junto con resección del pseudoaneurisma y ligadura de la arteria ilíaca. El estudio histológico de los pseudoaneurismas reveló la presencia de Aspergillus y se inició tratamiento con anfotericina B liposomal. La evolución clínica de las dos pacientes fue diferente. La paciente A falleció debido a complicaciones secundarias a una segunda intervención quirúrgica por recibida del aneurisma. La paciente B presentó una evolución favorable manteniéndose en la actualidad en programa de hemodiálisis (AU)

We describe a clinical case of two patients who received a cadaveric renal graft from the same donor in a multi-organ extraction procedure. The donor was a 39-years-old woman who died of intracraneal tumour. A benign ganglioma was shown in biopsy. The two recipients received the same inmunosupressive regimen. Induction comprised cyclosporin A, steroids and basiliximab while cyclosporin A and steroids were used in maintenance immunosupression. The A patient was a 53-years-old woman with chronic renal failure due to chronic pyelonephritis. She had been undergoing periodic haemodialysis for five years. She was hospitalised by sciatic pain refractive to rest and analgesics 35 days after transplantation. Two days later, her graft function deteriorated. Ultrasonography ruled out a urinary tract obstruction. Cyclosporine levels was normal. Was interpreted as an acute rejection episode and was treated with boluses of methylprednisolone (500 mg for 3 days). At the same time, her right leg began to show paraesthesia, coldness and a decreased of arterial pulse. A spinal magnetic nuclear resonance was performed. It showed an aneurysm of right common iliac artery (fig. 1). An arteriography confirmed the existence of a pseudoaneurysm and an arteriovenous fistula to inferior vena cava (fig. 2). The B recipient was a 56-years-old woman with chronic renal failure due to chronic pyelonephritis. She required haemodialysis for two years. In the 4th month after transplantation her graft function deteriorated. Graft biopsy did not show acute cellular rejection. So she was kept on immunosupressive treatment. A second graft biopsy was taken and no changes with the previous one was observed. Renal function deteriorated and haemodialysis was required. During the 6th month she began to show paraesthesia, coldness and decreased of arterial pulse in her right leg. Ultrasonography showed pyelocaliectasis with an adjacent solidliquid mass, abdominal CT scan confirmed. Arteriography proved the presence of a pseudoaneurysm of the right common iliac artery (fig. 3). Transplantectomy and pseudoaneurysm resection was taken in the two cases. Culture analysis revealed fungi identified as Aspergillus in both pseudoaneurysm. Medical treatment was started immediately with liposomal amphotericin B. The clinical evolution of the two recipients were different. While recipient A died, B patient recovered requiring haemodialysis (AU)

Lemierre syndrome variant: necrobacillosis associated with inferior vena cava thrombosis and pulmonary abscesses after trauma-induced leg abscess.

Fusobacterium necrophorum, a rarely encountered but potentially lethal bacterial pathogen, is the cause of Lemierre syndrome, an oropharyngeal infection complicated by jugular vein thrombophlebitis and metastatic septic embolization. We describe an unusual variant of this disease in a man who developed F necrophorum sepsis (associated with extensive inferior vena cava and common femoral vein thrombosis) and multiple abscesses in the lungs after a trauma-associated abscess of the left lower extremity. We highlight the predilection of F necrophorum to cause a potentially fatal septic illness irrespective of its primary focus and emphasize the importance of this bacterium as a cause of considerable morbidity.

Lactobacillus rhamnosus septicaemia in a patient with a graft in the inferior vena cava.

A case of septicaemia that repeatedly showed growth of Lactobacillus rhamnosus in blood cultures is reported. The patient improved after removal of a Goretex patch in the inferior vena cava that was the focus of the infection. Lactobacilli can, in certain settings, be the cause of clinically important infections.

Eustachian valve endocarditis: Is it worth searching for?

BACKGROUND: Only a few cases of eustachian valve endocarditis have been reported. Whether the eustachian valve is an uncommon site for a vegetation to be attached or whether the disease is missed because a systematic approach to this valve is not routinely performed in the search for vegetations is not known. METHODS: Every patient suspected of having endocarditis undergoes a specific approach, which includes a systematic study of the eustachian valve. In 10 patients with large valves but without signs and symptoms of endocarditis, we identified 2 specific findings: width <3 mm and a regular oscillating movement. A blinded evaluation in the 10 control subjects and 30 patients with right-sided endocarditis, including the 5 with eustachian valve endocarditis, showed an agreement of 97% (39/40). RESULTS: Five of 152 patients with right-sided endocarditis were found to have eustachian valve vegetations (3.3%). Patients were young (age range 22-34 years) and all had predisposing factors (3 intravenous drug abusers, 2 central venous lines), fever, and septic pulmonary embolism. Staphylococcus aureus was cultured in all cases. Tricuspid involvement was found in 4 patients, and only 1 patient had isolated eustachian valve endocarditis. All patients did well with culture-guided antibiotics. CONCLUSIONS: Our results suggest that eustachian valve endocarditis may be more frequent than is believed. Thus a systematic interrogation of the eustachian valve should be included in the echocardiographic examination of a patient suspected of having endocarditis.