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An Unusual Case of Polymicrobial Bacteremia
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An Unusual Case of Polymicrobial Bacteremia Q2
Ahmed Akhter,1,3 Erin Brooks,2,3 and Patrick Pfau1,3 1
Division of Gastroenterology and Hepatology, 2Department of Pathology and Laboratory Medicine, 3University of Wisconsin, Madison, Wisconsin
Question: A 75year-old woman with a history of chronic obstructive lung disease, alcoholic cirrhosis, and a recent episode of polymicrobial bacteremia (Enterococcus avium and Bacteroides) at an outside hospital 2 months before presentation was admitted with shortness of breath and abdominal pain. Blood cultures on hospital day 1 demonstrated vancomycin-resistant enterococcus bacteremia. She was placed on daptomycin but developed hypotension, oliguria, and altered mental status. She was diagnosed with septic shock. Review of a recent computed tomography (CT) of the abdomen and pelvis at the time of polymicrobial bacteremia demonstrated an intrauterine device (IUD) that had migrated out of the uterus (Figure A). The IUD was removed the next day. A barium enema performed the following day was reported to demonstrate a contained perforation (Figure B). Evaluation of potential infectious source was performed, including esophagogastroduodenoscopy, small bowel capsule endoscopy, chest radiography, whole body positron emission tomography/CT, hepatobiliary scan, transthoracic echocardiogram, CT angiogram of the abdomen and pelvis, flexible sigmoidoscopy, paracentesis, endoscopic retrograde cholangiopancreatography, and indium-tagged white blood cells. However, all tests were either negative or noncontributory to the etiology of polymicrobial bacteremia. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.08.063
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60703 proof 2 March 2017 12:58 am ce
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 5: Colovenous Fistula
Review of the barium enema performed at the outside hospital revealed extravasation of barium at the sigmoid colon with possible fistula to the uterus (Figure C, arrow points to uterine fibroid). The patient further deteriorated with hypoxic respiratory failure and was not considered a surgical candidate for exploratory laparotomy given Child-Pugh class C liver disease. Given her poor prognosis after several episodes of pulseless electrical activity, the decision was made to pursue comfort care. An autopsy was requested by family and clinical team to search for a bacteremic source and explain the cause of death. At autopsy extensive fibrous adhesions were noted extending between the sigmoid colon and uterus (Figure D). This adhesion most likely corresponds with the healed perforation site secondary to the displaced IUD. Microscopically within the lungs, an extensive intravascular giant cell reaction was seen along with foci of vegetable matter (Figure E, arrows). This finding can be seen in patients who crush and inject pills (eg, talc granulomatosis)1; no characteristic polarizable talc or microcrystalline cellulose crystals were seen in our patient. In cases of aspiration, plant material is localized to the respiratory airways rather than pulmonary vasculature. The location of plant material in the pulmonary vasculature in conjunction with the history of a radiographically documented intestinal perforation in the setting of IUD migration is most suggestive of a colovenous fistula. It is most likely that, during the earlier perforation, a small fistula formed between the sigmoid colon and nearby pelvic vein(s), through which fecal/vegetable materials circulated back to the intrapulmonary vessels, inducing a giant cell reaction. Fistulation between the gastrointestinal tract and the vascular system most commonly occurs in the setting of wall damage such as from catheter tip migration, colonic diverticulitis, or Crohn’s disease with deep fissuring.2 Although colovenous fistula is rarely reported, it is lethal with two reports demonstrating a colonic fistula to the inferior mesenteric vein3 and should be considered in the setting of polymicrobial sepsis.
References 1. 2. 3.
Low SE, Low SU, Nicol A. Talc induced pulmonary granulomatosis. J Clin Pathol 2006;59:223. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology 2002;224:9–23. Rossmann MD, Burr LJ, Thorpe PE. Colovenous fistula complicating diverticulitis: CT and radiographic findings. Abdom Imaging 1997;22:513–515.
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An Unusual Case of Polymicrobial Bacteremia Q2
Ahmed Akhter,1,3 Erin Brooks,2,3 and Patrick Pfau1,3 1
Division of Gastroenterology and Hepatology, 2Department of Pathology and Laboratory Medicine, 3University of Wisconsin, Madison, Wisconsin
Question: A 75year-old woman with a history of chronic obstructive lung disease, alcoholic cirrhosis, and a recent episode of polymicrobial bacteremia (Enterococcus avium and Bacteroides) at an outside hospital 2 months before presentation was admitted with shortness of breath and abdominal pain. Blood cultures on hospital day 1 demonstrated vancomycin-resistant enterococcus bacteremia. She was placed on daptomycin but developed hypotension, oliguria, and altered mental status. She was diagnosed with septic shock. Review of a recent computed tomography (CT) of the abdomen and pelvis at the time of polymicrobial bacteremia demonstrated an intrauterine device (IUD) that had migrated out of the uterus (Figure A). The IUD was removed the next day. A barium enema performed the following day was reported to demonstrate a contained perforation (Figure B). Evaluation of potential infectious source was performed, including esophagogastroduodenoscopy, small bowel capsule endoscopy, chest radiography, whole body positron emission tomography/CT, hepatobiliary scan, transthoracic echocardiogram, CT angiogram of the abdomen and pelvis, flexible sigmoidoscopy, paracentesis, endoscopic retrograde cholangiopancreatography, and indium-tagged white blood cells. However, all tests were either negative or noncontributory to the etiology of polymicrobial bacteremia. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Q1
Conflicts of interest The authors disclose no conflicts. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.08.063
Gastroenterology 2017;-:e1–e2 DIS 5.4.0 DTD YGAST60703 proof 2 March 2017 12:58 am ce
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ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 5: Colovenous Fistula
Review of the barium enema performed at the outside hospital revealed extravasation of barium at the sigmoid colon with possible fistula to the uterus (Figure C, arrow points to uterine fibroid). The patient further deteriorated with hypoxic respiratory failure and was not considered a surgical candidate for exploratory laparotomy given Child-Pugh class C liver disease. Given her poor prognosis after several episodes of pulseless electrical activity, the decision was made to pursue comfort care. An autopsy was requested by family and clinical team to search for a bacteremic source and explain the cause of death. At autopsy extensive fibrous adhesions were noted extending between the sigmoid colon and uterus (Figure D). This adhesion most likely corresponds with the healed perforation site secondary to the displaced IUD. Microscopically within the lungs, an extensive intravascular giant cell reaction was seen along with foci of vegetable matter (Figure E, arrows). This finding can be seen in patients who crush and inject pills (eg, talc granulomatosis)1; no characteristic polarizable talc or microcrystalline cellulose crystals were seen in our patient. In cases of aspiration, plant material is localized to the respiratory airways rather than pulmonary vasculature. The location of plant material in the pulmonary vasculature in conjunction with the history of a radiographically documented intestinal perforation in the setting of IUD migration is most suggestive of a colovenous fistula. It is most likely that, during the earlier perforation, a small fistula formed between the sigmoid colon and nearby pelvic vein(s), through which fecal/vegetable materials circulated back to the intrapulmonary vessels, inducing a giant cell reaction. Fistulation between the gastrointestinal tract and the vascular system most commonly occurs in the setting of wall damage such as from catheter tip migration, colonic diverticulitis, or Crohn’s disease with deep fissuring.2 Although colovenous fistula is rarely reported, it is lethal with two reports demonstrating a colonic fistula to the inferior mesenteric vein3 and should be considered in the setting of polymicrobial sepsis.
References 1. 2. 3.
Low SE, Low SU, Nicol A. Talc induced pulmonary granulomatosis. J Clin Pathol 2006;59:223. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology 2002;224:9–23. Rossmann MD, Burr LJ, Thorpe PE. Colovenous fistula complicating diverticulitis: CT and radiographic findings. Abdom Imaging 1997;22:513–515.
e2 DIS 5.4.0 DTD YGAST60703 proof 2 March 2017 12:58 am ce
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