Between cancer and sepsis: an atypical case of splenic vein thrombosis

Abstract

Pylephlebitis, defined as septic thrombophlebitis of the porto-splenic venous system, is an uncommon but serious complication of intra-abdominal infections, associated with significant morbidity and mortality if not recognized promptly. We report the case of a 71-year-old woman with a history of stage III (T3N2M0) biliopancreatic adenocarcinoma complicated by peritoneal recurrence and multiple surgical procedures. She presented with a high-grade fever of 40°C, generalized jaundice, dark urine, and watery stools without mucus or blood. On physical examination, there was noticeable Boyd grade 1 splenomegaly. Laboratory evaluation revealed leukopenia, anemia, and thrombocytopenia, along with a mixed hepatocellular–cholestatic pattern, elevated acute-phase reactants, and a blood culture positive for Streptococcus sanguinis. Imaging studies, including contrast-enhanced abdominopelvic CT and magnetic resonance cholangiography, revealed the following findings: interruption of the splenic vein across multiple segments, numerous perigastric and perisplenic collaterals, mild pneumobilia, intrahepatic biliary dilatation, splenomegaly, and a pancreatic stent displaced toward the splenic hilum. These findings were consistent with partial obstruction of splenic venous flow in the setting of an acutely exacerbated chronic process, likely secondary to paraneoplastic hypercoagulability, extensive post-surgical inflammatory changes, and extrinsic mechanical compression. The patient showed a favorable response to antibiotic, anticholestatic, and anticoagulant therapy, and was discharged on the eighth day of hospitalization with continuation of the same long-term treatment regimen. Given the rarity of pylephlebitis and the nonspecific nature of its clinical presentation, a comprehensive review of this condition is warranted, highlighting the need for a multidisciplinary approach to ensure timely evaluation, diagnosis, and management.