A 54-year-old man was admitted to the hospital on July 13, 2022, complaining of fatigue and decreased appetite for over two weeks. He experienced loose stools and defecated once a day during the onset of the disease. The patient had a history of type 2 diabetes for 15 years and had undergone Whipple surgery more than 10 years ago, although the pathological results were unavailable. He had also previously contracted tuberculosis but had successfully recovered after receiving regular treatment.
Shortly after admission, the patient's temperature increased from 37.8 ℃ to 40.9 ℃, accompanied by an elevation in heart rate(HR) from 129 bpm to 143 bpm. He experienced mild tightness in the chest, shortness of breath, and coughing with white phlegm. Diagnostic tests revealed sinus tachycardia on electrocardiogram, along with abnormal blood parameters: WBC 7.5× 10^9/L, Neutrophils 96.8%, hemoglobin 93g/L, PLT 103×10^9/L, CRP 237.26mg/L, and lactate 2.80mmol/L. Cardiac troponin, myocardial enzyme spectrum, electrolytes, and renal function showed no significant abnormalities.Chest CT scans showed scattered infectious lesions in both lungs, residual lesions with bronchial dilation, an enlarged heart with pericardial effusion, and widened pulmonary arteries(Fig. 1). The patient was diagnosed with pneumonia complicated by septic shock. Diagnosed with pneumonia complicated by septic shock, the patient received rapid fluid infusion and was prescribed acetaminophen and cefoperazone sulbactam. However, despite treatment, the patient's high fever, chills, elevated heart rate, and unstable blood pressure persisted. He was promptly transferred to the Intensive Care Unit (ICU) at 2:30am the following day.
In the ICU, an echocardiography revealed a hypoechoic mass approximately 1.3 * 3.5cm near the right atrium entrance within the posterior segment of the inferior vena cava (IVC), suggesting thrombosis(Vedio 1). Subsequent tests ruled out tuberculosis recurrence. An enhanced abdominal CT scan indicated postoperative changes in the stomach,pancreatic duct stent left over from surgery, slight gastric wall thickening, fatty liver, spleen enlargement, abdominal fluid accumulation, peritoneal mesenteric space changes, colonic liver curvature wall thickening and edema, and insufficient filling of the hepatic segment of the IVC(Fig. 2).
Vedio1:A hypoechoic mass of approximately 1.3 * 3.5cm in the posterior hepatic segment of the inferior vena cava, swaying with blood flow.
After treatment with Meropenem and heparin, the patient returned to the general ward on the fifth day and stopped using heparin. Two weeks later, the patient was considered "recovered" with normal body temperature and echocardiography(Fig. 3). However, four days after normalizing body temperature, he experienced another high fever episode, accompanied by elevated PCT, CRP, WBC, and neutrophil levels. Follow-up echocardiography did not reveal significant abnormalities. CT venography (CTV) of the IVC showed worsening thrombosis extending into the right hepatic vein(Fig. 4). Blood culture results were positive for Pseudomonas aeruginosa and fecal Enterococcus. Based on the medical history and multidisciplinary discussions, the diagnosis is septic thrombophlebitis of the IVC(IVCST). The patient received a combination of piperacillin-tazobactam (4.5g q6h), amikacin (0.2g q12h), and heparin based on drug sensitivity tests.After three weeks, the patient recovered and was discharged. Following discharge, the patient continued taking 60mg of idoxaban orally every day.
During the eleven-month follow-up period, the patient did not experience further episodes of fever. A follow-up CT scan of the IVC indicated a significant reduction in the size of the IVC thrombus compared to before(Fig. 5).