Spondylodiscitis associated with recurrent Serratia bacteremia due to a transjugular intrahepatic portosystemic shunt (TIPS): a case report

Abstract

We report a case of spondylodiscitis caused by multiresistant Serratia marcescens in a cirrhotic patient who had several Serratia bacteremias after the placement of a transjugular intrahepatic portosystemic shunt (TIPS) device. We concluded that an endovascular stent that can not be removed makes management of recurrent bacteremia difficult. Furthermore, back pain due to bacteremia is indicative of spondylodiscitis. Serratia marcescens can be an aggressive pathogen, causing spinal infection. Key-Words: Serratia marcescens, recurrent bacteremia, spondylodiscitis, TIPS. Case ReportA 59-year-old Caucasian man had liver cirrhosis due to alcohol abuse, which was complicated by portal hypertension and esophageal varices. Because of acute upper gastroenterological bleeding and transesophageal sclerosis of varices, he underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure performed at our hospital. As he also had aspiration pneumonia, intravenous antibiotic therapy with cefoxitin was done for four days. There was gradual clinical improvement, and he was transferred to his local hospital. However, blood cultures collected seven days after TIPS revealed Serratia marcescens, which was only susceptible to cefotaxime, ceftazidime and imipenem. Imipenem was administered during seven days.Three weeks after TIPS, the patient developed low-back pain and fever (38.5ºC), without neurological involvement. Lumbar radiography and computed tomography were compatible with degenerative processes. The blood cultures showed S. marcescens, which was susceptible to the previously-mentioned antibiotics. Imipenem was reinitiated for another seven days. Ten weeks after TIPS, he was transferred to our department to determine the source of the bacteremia. On admission, he complained of worsening lowback pain, and he was febrile (38.3ºC). Laboratory blood examination showed C-reactive protein to be 5.7 mg/dL (normal values: 0.0-0.5 mg/dL), erythrocyte sedimentation rate 48 mm/ hr and white blood cell counts 8.8x10 9 /L, with 75% segmented neutrophils. The blood cultures revealed S. marcescens, which was only susceptible to imipenem.A gallium-67 citrate scan revealed an increased uptake at D9-D11, probably due to spondylodiscitis, which was confirmed by bone scanning with technetium-99m and magnetic resonance imaging. He had no central line devices, and the urine cultures were negative. The abdominal Doppler ultrasound showed a TIPS stent with a normal-direction blood flow. Abdominal ultrasound and chest X-rays, as well as transthoracic echocardiography, were normal.The patient could only walk with the aid of a thoracolumbar brace, and imipenem was administered from the 10 th until the 45 th week after TIPS, with substantial clinical improvement and discrete imaging symptom stabilization. His next presentation was 48 weeks after TIPS, with a recrudescence of fever, despite 36 weeks of antibiotic therapy. He had a satisfactory clinical condition, no longer wore a lumbar support, and the lab data (ESR, CRP, WBC) showed a good re...

Endotipsitis-persistent infection of transjugular intrahepatic portosystemic shunt: pathogenesis, clinical features and management

“…Hepatomegaly, increasing ascites and recurrent variceal bleeding were also described and attributed to TIPS occlusion (36, 37). Other signs of bacteremia and endovascular infection have been reported and include purpuric lesions, back pain and limb weakness secondary to vertebral osteomyelitis and spondylodiscitis, and signs and symptoms associated with septic pulmonary emboli (23, 25, 38).…”

“…Also, Enterobacteriaceae were uncommon causative agents in early endotipsitis with only one described case of P. aeruginosa and one case of S. marcescens occurring 35 and 30 days after TIPS respectively Thus, the most common organisms in early endotipsitis were Staphylococci and other Gram‐positive bacteria (isolated in 72% of cases) and enterococci spp. (33, 36, 38, 41–43).…”

A Case of Lumbar Vertebral Osteomyelitis Following Community-Acquired Serratia Marcescens Bacteremia with Enteritis

“…It is important to know it as a pathogen of the nosocomial infection, associated with outbreaks of nosocomial infections [8]. The incident rate of nosocomial bacteremia of Serratia species is 1.2 to 1.4 % [9][10][11][12] and the incidence of the community acquired bacteremia was only 0.49 per a population 100,000 people [13]. Gastrointestinal as being the focus of infection of the community acquired Serratia marcescens bacteremia is extreme rare [5].…”