Case 282: Fishbone Pylephlebitis

History A 63-year-old woman with a history of left mastectomy for breast cancer and partial gastrectomy with Roux-en-Y reconstruction for nonhealing peptic ulcer presented to the emergency department and reported a 1-month history of abdominal distention, fevers, chills, and flu-like symptoms. She was initially suspected of having flu, and she completed a course of oseltamivir; however, she had continued to experience fatigue, fever, chills, abdominal bloating, and loss of appetite. She reported no contact with a sick person or recent travel. At admission, laboratory studies revealed leukocytosis, with a white blood cell count of 15.1 x 103/mu L (15.1 x 109/L) (normal range, 4.0-10.0 x 103/mu L [4.0-10.0 x 109/L]), an elevated sedimentation rate of 100 mm per hour (normal range, 0-30 mm per hour), and a C-reactive protein level of 203.8 mg/L (1940.9 nmol/L) (normal range, <= 10 mg/L [<= 95.2 nmol/L]). Liver enzyme levels were elevated, with an alanine aminotransferase level of 48 U/L (0.80 mu kat/L) (normal range, 0-29 U/L [0-0.48 mu kat/L]), an aspartate aminotransferase level of 98 U/L (1.6 mu kat/L) (normal range, 10-37 U/L [0.16-0.62 mu kat/L]), an alkaline phosphatase level of 682 U/L (11.4 mu kat/L) (normal range, 65-195 U/L [1.1-3.3 mu kat/L]), and a total bilirubin level of 1.5 mg/dL (25.7 mu mol/L) (normal range, 0.3-1.0 mg/dL [5.1-17.1 mu mol/L]). Abdominopelvic CT was performed.