CASE REPORTS Torulopsis glabrata Fungemia as a Complication of a Clotted Transjugular Intrahepatic Portosystemic Shunt Peter Darwin,* Wolfgang Mergner,* and Paul Thuluvath† Torulopsis glabrata fungemia developed in a patient with a clotted transjugular intrahepatic portosystemic shunt (TIPS) 11 months after placement. Fungemia persisted despite treatment with amphotericin B. On autopsy, T. glabrata was found in the thrombus occluding the TIPS and extending into the splenic and portal vein. TIPS infections may be considered in patients with fungemia. Copyright r 1998 by the American Association for the Study of Liver Diseases orulopsis glabrata ( Candida glabrata) is considered to be a saprophyte of humans and to be of limited pathogenicity. 1 Under conditions of altered resistance, this yeast can become pathogenic.2 We report a patient with T. glabrata fungemia from a clotted transjugular intrahepatic portosystemic shunt (TIPS) that was seeded with yeast. Discussion T Case Report A 55-year-old man with end-stage liver disease secondary to cryptogenic cirrhosis underwent TIPS for recurrent variceal bleeding. Two revisions for stent occlusion were done over the next 6 months while he awaited liver transplantation. He was admitted 11 months after TIPS placement with right upper quadrant pain and fever. Evaluation included a right upper quadrant ultrasound that showed a thick-walled gallbladder with cholelithiasis, no ductal dilatation or TIPS flow, bilirubin of 24 mg/dL (direct 15), and alkaline phosphatase of 43 U/L. Broad-spectrum antibiotic therapy was begun, and the patient underwent endoscopic retrograde cholangiopancreatography that showed no common duct stones. Blood cultures drawn 7 days after admission grew T. glabrata. Amphotericin B was started, and the patient underwent cholecystectomy. Complications during hospitalization included a perioperative myocardial infarction and renal failure. Despite 26 days of amphotericin therapy (total, 1,950 mg) and additional flucytosine, multiple blood cultures remained positive for T. glabrata. A transthoracic cardiac echo showed no vegetations. The patient was transferred to our hospital and died on day 27 after the initial admission. On autopsy, T. glabrata was found in thrombus that occluded the TIPS and extended into the splenic and portal vein with no other sites of infection or thrombus found. T. glabrata may be found in the skin and mucous membranes of healthy individuals. Fungemia has been reported in patients with underlying debilitating conditions and most commonly presents as high fever and hypotension.1 An increasing incidence of infection is thought to be secondary to aggressive therapy with antibiotics, corticosteroids, and surgical techniques.2,3 The literature shows a continually broadening spectrum of infectious sites.3-5 Reports have shown T. glabrata fungemia associated with thrombophlebitis and hepatic abscesses that cleared with antifungal therapy.1,2 Our case showed persistent fungemia despite treatment. Because T. glabrata is sensitive to amphotericin B, a nidus of infection was sought. Because T. glabrata has been described as causing acute cholecystitis,6 a cholecystectomy was performed. Postoperative fungal cultures were persistently positive. An infected, thrombosed TIPS was suspected and confirmed at autopsy. TIPS has gained widespread acceptance as a therapeutic tool for the treatment of portal hypertension and a bridge to transplantation. Chronic TIPS complications include shunt stenosis, en- From the *Division of Gastroenterology and Department of Pathology, University of Maryland Medical Center, and the †Division of Gastroenterology, The Johns Hopkins Hospital, Baltimore, MD Address reprint requests to Peter Darwin, MD, University of Maryland Medical Center, Division of Gastroenterology, N3W62, 22 S Greene St, Baltimore, MD 21201. Copyright r 1998 by the American Association for the Study of Liver Diseases 1074-3022/98/0401-0012$3.00/0 Liver Transplantation and Surgery, Vol 4, No 1 ( January), 1998: pp 89-90 89 90 Darwin, Mergner, and Thuluvath for transplantation or TIPS reintervention. A recent case report from Germany noted success with shunt dilatation and local and systemic thrombolysis with tissue plasminogen activator in a patient with portal vein thrombosis and TIPS occlusion.10 Theoretically, patients with TIPS thrombosis and clot infection should be considered for clot biopsy to confirm the diagnosis, then for thrombolysis and shunt dilatation because the morbidity and mortality of hepatic transplantation may prove prohibitive. T. glabrata should be considered a potential cause for fungemia in patients with clotted TIPS, and early intervention is indicated because antifungal therapy may fail to clear the infection. References cephalopathy, portal vein thrombosis, and progressive hepatic failure.7 Portal or splenic vein thrombosis is reported in 1% to 15% and shunt stenosis in 33% to 66% of cases 6 to 12 months after placement.8,9 To our knowledge, this is the first case describing T. glabrata fungemia secondary to a thrombosed TIPS. It is unclear whether the infected thrombus was the primary problem on admission or a process secondary to antibiotic therapy and seeding from another source. Because the patient was hypotensive with concurrent medical issues when he was transferred to our institution, he was not considered a candidate 1. Morris JT, McAllister CK. Fungemia due to Torulopsis glabrata. South Med J 1993;86:356-357. 2. Friedman E, Blahut R, Bender M. Hepatic abscess and fungemia from Torulopsis glabrata. J Clin Gastroenterol 1987;9:711-715. 3. Connolly JP, Mitas JA. Torulopsis glabrata fungemia in a diabetic patient. South Med J 1990;83:352-353. 4. Mandell GL. Candida species. In: Mandell GL (ed). Principles and practice of infectious disease. New York: Churchill Livingstone, 1995:2289-2301. 5. Komshian SV, Uwaydah AK, Sobel JD, Crane LR. Fungemia caused by Candida species and Torulopsis glabrata in the hospitalized patient: frequency, characteristics and evaluation of factors influencing outcome. Rev Infect Dis 1989;11:379-390. 6. Valainis GT, Sachitamo RA, Pankey GA. Cholecystitis due to Torulopsis glabrata. J Infect Dis 1987;156:244245. 7. Kamath PS, Mckusick MA. Transvenous intrahepatic portosystemic shunts. Gastroenterology 1996;111:17001705. 8. Shiffman ML, Jeffers L, Hoofnagle JN, Tralka TS. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and complications: a conference sponsored by the National Digestive Diseases Advisory Board. Hepatology 1995;22(suppl):15911597. 9. Coldwell DM, Ring EJ, Rees CR, Zemel G, Darcy MD, Haskal ZJ, et al. Multicenter investigation of the role of TIPS in the management of portal hypertension. Radiology 1995;196:340-355. 10. Gabler R, Barnert J, Bohndorf K, et al. Portal vein thrombosis after occlusion of a TIPS shunt dilatation with subsequent local and systemic thrombolysis. Dtsch Med Wochenschr 1997;122:188-192.